Professionalism and ethics are critical components in physician development. They play an integral part in every patient encounter and serve as "the basis of medicine's contract with society" (1). Professionalism is also included as one of the six core areas in which all physicians in training must demonstrate competence, according to the Accreditation Council of Graduate Medical Education (2). Previous studies have noted that physicians in training often experience ethical conflicts, and they value training that enables them to better deal with such issues (3—8). Furthermore, both medical students and residents have voiced interest in a variety of ethical topics and have strongly endorsed the relevance of such teaching to their everyday clinical practice (5, 7, 9).
In 1996, a multisite survey of 181 United States psychiatry residents (9) found that even though more than three-quarters of the respondents had faced an ethical dilemma for which they felt unprepared, only half had ever received any ethics training in residency. The residents noted a need for training in defining the boundaries of what can be done legally in responding to difficult ethical dilemmas, clarifying the ethical issues in social policy, and providing good care to psychiatric patients. They believed that the best approach for teaching these topics would be through learning from experts, exploring topics of clinically relevant material, and teaching and learning from peers. In 2004, Roberts et al. (10) surveyed medical students and residents at one academic center. Fewer than 1 out of 5 respondents believed that their ethics preparation was sufficient. In findings similar to those of the 1996 study (9), respondents preferred clinically- and expert-oriented learning over formal, nontraditional, or independent approaches.
As program directors consider educational programs to address these needs, it is important that such initiatives have clear goals, address relevant areas in a useful manner, and are effective for residents or medical students (11—17). Previous data have shown the value of assessing trainees' attitudes, views, and preferences when developing professionalism-educational initiatives (18—23). The intent in creating curricula and utilizing teaching methods attuned to participants' goals and preferences is that such education would translate to better clinical care in day-to-day practice.
To our knowledge, no recent comprehensive study investigates such views of psychiatry residents; hence, we conducted a multisite survey of psychiatry residents to investigate current perspectives about the goals of ethics and professionalism education, what learning methods should be used, and upon what ethical principles curricula should be based. From the existing literature (9, 10), we hypothesized that psychiatry residents would continue to value ethics training as a relevant part of medical education, place more value on ethics training and curricula viewed as more relevant to addressing day-to-day clinical situations, and specifically value the expertise of their clinician teachers.
In Spring 2005, all postgraduate years (PGY) 1—6 psychiatry residents (N=249) at seven training programs were invited to participate in this self-report survey study. The sites, chosen for convenient sampling and to represent a range of psychiatric training settings, were the Mayo Clinic (N=35), Medical College of Wisconsin (N=32), University of Arkansas for Medical Sciences (N=23), University of California San Diego, CA, School of Medicine (N=54), University of Chicago Pritzker School of Medicine (N=25), University of Massachusetts Medical School (N=28), and Walter Reed Army Medical Center (N=52). A total of 151 usable surveys were returned, for an overall response rate of 61%.
The survey instrument was based on a questionnaire developed at the University of New Mexico (UNM) to assess views of medical students and residents regarding professionalism, ethics preparation, and their evaluation in medical education. Results of the UNM survey have been published elsewhere (6, 10, 24). The original instrument contained 124 items, organized by 10 domains, which were derived from the American Board of Internal Medicine's definition of professionalism (1): attitudes, goals, learning methods, curricula, knowledge assessment, skills assessment, and educational needs concerning informed-consent topics, principles, vulnerable populations, and relationship boundaries. Content items were rated on 9-point scales (1: None to 9: Very Much). Twenty-eight questions relevant to psychiatric residency training were added to the original instrument. The revised instrument contained 149 questions in the 10 content domains, with 6 questions regarding personal ethics experiences during training and 5 demographic questions. Here, we report findings from items assessing attitudes toward the goals of education in professionalism and ethics, preferred educational methods, and views of the importance of specific educational topics and curriculum content.
The survey was distributed to psychiatry residents at each site with a cover letter indicating the purpose of the study, anonymity procedures, and Institutional Review Board approval. A package of candy was included with the survey as a token compensation. Two follow-up surveys were distributed at 1-month intervals, with a request to complete the questionnaire only if the recipient had not already done so. Completed surveys were collected at each site and mailed unopened to the Medical College of Wisconsin for data entry and analysis. The Institutional Review Boards of all seven sites reviewed the survey protocol and approved the study or found it exempt.
Conceptually-related sets of 9-point scaled rating responses were subjected to repeated-measures Item (within-subjects repeated measures) x School (between subjects) x Gender (between subjects) MANOVAs. Four cases were excluded from the curricula item-set analysis because of missing values. We examined correlations among items and the six questions regarding personal ethics experiences during training.
A total of 151 psychiatry residents from seven medical schools participated in our survey; response rates varied from 51% to 77% across schools, with an overall response rate of 61% (Table 1). Residents were 13% PGY-1 training level, 21% PGY-2, 30% PGY-3, 23% PGY-4, and 13% PGY-5 or −6. Overall, about half (47%) were women; gender composition varied among schools from 25% to 75% women (p<0.02). The majority (59%) were married or living with a partner. Overall, three-fourths (75%) of respondents were white, 17% African American, 4% Asian American, and 4% of other or unreported ethnicity. Ethnic composition varied among schools (p<0.01), from 47% to 93% white, 0% to 47% African American, and 0% to 19% Asian American. Mean (standard deviation [SD]) age was 31.1 (4.4) years.
TABLE 1.Participant Characteristics (N=151)
Residents had encountered ethical conflicts to a moderate degree during training (mean: 5.16 on a scale of 1: Never to 9: Constantly); 3% (N=4) of respondents indicated "None" for amount of ethics training received during medical school, and 4% (N=6) indicated "None" during residency. Overall, respondents had received a moderate amount of ethics training during medical school (mean: 5.20 on a scale of 1: None to 9: Very Much) and some ethics training during residency (mean: 4.60). Ethics training during residency ranged from a little (mean: 2.93) to a moderate amount (mean: 5.44) across schools (p<0.01). Residents reported that their overall medical education had helped somewhat to deal with ethical conflicts (mean: 5.62 on a scale of 1: Not at All to 9: Very Much). Respondents reported that many of their supervising residents and faculty had been positive role models of ethical and professional behavior (mean: 6.60 on a scale of 1: None to 9: All) and that they had usually been treated in an ethical and professional manner by supervising residents, faculty, and their training institution (mean: 6.88 on a scale of 1: Never to 9: Always).
Goals of Education in Professionalism and Ethics
Psychiatry residents rated agreement with 11 goals of medical education in professionalism and ethics (Table 2). Residents agreed that the goals of education are to help residents improve patient care and clinical decision-making; better recognize ethical issues; develop interpersonal skills useful in resolving ethical conflicts; better clarify value-laden choices; reduce the likelihood that a physician may make an ethical error in the future; and acquire a working knowledge of social science, philosophy, religion, and law as they apply to clinical care (means: 6.59 to 7.49). Residents agreed less, but still agreed, that the goals of education are to help residents reduce the likelihood that a physician may make a legal error in the future, learn how to heal patients in addition to treating them, prevent cynicism and detachment in interactions with patients, and reduce the likelihood that a clinician will face a medical liability suit at some point during practice (means: 5.94 to 6.41). Residents neither agreed nor disagreed that the goal of education in professionalism and ethics is to help residents become better people (mean: 5.29; Item main effect F [10, 128]=20.84; p<0.0001, maximum Cohen's δ=1.15). There was no consistent pattern of correlation among agreement with the stated goals and personal ethics experience during training.
TABLE 2.Goals of Medical Education in Professionalism and Ethics Rated by 151 Psychiatry Residents at Seven Medical Schools
Respondents rated agreement that 19 methods are effective for learning about professional attitudes, values, and ethics (Table 3). Psychiatry residents agreed most that role modeling of ethical reasoning and behavior by faculty, discussion groups of peers led by a knowledgeable clinician, incorporation of ethical issues into lecture and teaching rounds, clinical rounds, case conferences, interactions with patients in routine training situations, and discussion of clinical ethics with ethics consultants were effective learning methods (means: 6.70 to 7.72). Residents also agreed that discussion of the cultural aspects of patient care with cultural experts, Grand Rounds presentations, discussion of the legal aspects of patient care with attorneys, discussion of the spiritual aspects of patient care with chaplains, lectures, watching videotapes on ethics topics followed by discussion led by a knowledgeable clinician, discussion groups of peers without leadership by a clinician, directed reading with tutorial discussions, and directed ethics research with a mentor were effective (means: 5.52 to 6.31). Respondents overall neither agreed nor disagreed that independent reading was effective (mean: 5.23) and slightly disagreed that web-based educational approaches were effective (means: 4.62 to 4.66; Item main effect F [18, 120]=26.15; p<0.0001, maximum Cohen's δ=1.59). There was more diversity of opinion concerning the three lowest-ranked methods than the three highest-ranked methods (SDs: 2.09 to 2.27 versus 1.19 to 1.52; all p<0.001).
TABLE 3.Methods of Learning About Professional Attitudes, Values, and Ethics, Rated by 151 Psychiatry Residents at Seven Medical Schools
Psychiatry residents' ratings for some methods of learning about professional attitudes, values, and ethics differed across the seven medical schools (Item x School interaction F [108, 695]=1.85; p<0.0001). The maximum of the School means exceeded the minimum by more than one SD for five of the rated learning methods. School means ranged from neither agreement nor disagreement to agreement that the learning method was effective for Grand Rounds presentations (means: 5.13 to 7.29; δ=1.16), lectures (means: 4.95 to 6.96; δ=1.08), and videotapes on ethics topics followed by discussion led by a clinician (means: 4.63 to 6.99; δ=1.27). School means ranged from disagreement to agreement that the method was effective for discussion groups of peers without leadership by a clinician (means: 4.07 to 6.39; δ=1.25) and interactions with standardized patients (means: 3.21 to 6.73; δ=1.89). Less agreement that interactions with standardized patients was an effective learning method for professionalism and ethics was associated with more personal encounters with ethical conflicts (r = —0.20; p<0.02) and with less training in ethics, perceived helpfulness of training, positive role models, and being treated in an ethical and professional manner during medical training (r = 0.21 to 0.25; mean r=0.22; all p<0.01).
Psychiatry residents rated agreement that principle-, casuistry-, virtue-, and utilitarian-based approaches are effective curricula on professional attitudes, values, and ethics (Table 4). Residents agreed that all four approaches are effective (means: 6.26 to 6.65). Diversity of opinion was limited; for each approach, at least 72% of respondents agreed (responses of 6, 7, 8, or 9) that the approach was effective, and no more than 15% of respondents disagreed (responses of 1, 2, 3, or 4). Stronger agreement that principle-, casuistry-, and virtue-based approaches are effective was associated with greater perceived helpfulness of medical education in dealing with ethical conflicts (r=0.18 to 0.22; mean r=0.20; all p<0.03) and more experience of the supervising residents and faculty as positive role models and of ethical and professional treatment of trainees (r=0.16 to 0.31; mean r=0.26; all p<0.06).
TABLE 4.Effective Curricula Rated by 147 Psychiatry Residents at Seven Medical Schools
This study offers a current assessment of the perspectives of 151 psychiatry residents from across the United States. Residents continue to encounter ethical conflicts during training, have received moderate amounts of ethics training during medical school and residency, and find medical education helpful in dealing with such conflicts.
The amount of ethics training residents report they have received appears to have increased, as compared with findings reported in 1996. In that survey (9), 46% of residents from 10 U.S. training programs reported receiving no ethics training during residency, in contrast with this sample, who rated their ethics training during residency on a scale of 1: None to 9: Very Much from a little (mean: 2.93) to a moderate amount (mean: 5.44) across schools (mean: 4.6). This is encouraging, given findings from previous work that psychiatry residents—when compared with medical students and residents in other specialties—were especially receptive to ethics education, affirmed several goals for ethics and professionalism preparation, and believed in the effectiveness of many learning methods (10).
Residents believed that the most valuable goals of professionalism and ethics education related to being able to improve patient care and decision-making, better recognizing ethical issues, and developing interpersonal skills useful in resolving ethical conflicts. These findings echo the previous study (9), in which psychiatry residents showed strong interest in educational initiatives that would help them act for the betterment of their patients.
Learning methods involving role-modeling by faculty, expert leaders of group discussions, and clinically-based scenarios were strongly preferred, irrespective of training level or gender. This is consistent with findings from other medical fields. For instance, a study of physical therapy students noted that a case-based teaching method requiring critical thinking and problem-solving helped sensitize students to ethical subtleties in clinical practice (25). Furthermore, our findings are consistent with a similar survey of medical students and residents (10) also reporting that respondents had lower preferences for more individually-based learning, such as independent reading and web-based approaches. These views, although needing replication, should be factored into considerations for future ethics education and assessment methods (26).
Psychiatry residents rated agreement that principle-, casuistry-, virtue-, and utilitarian-based approaches were all effective ways of creating curricula on professional attitudes, values, and ethics, and diversity of opinion was limited. This finding raises the question of how familiar residents are with such approaches, the degree of education they have received in previous training about such methods and philosophies, and whether indeed they were prepared to delineate among such approaches in a discriminating fashion when answering the survey.
Finally, the survey highlights the importance of the cultural environs in which residents learn. Residents continue to prefer to learn about how to be ethical psychiatrists from faculty role models, yet this learning seems to make more of an impression on the recipients if they perceive themselves to have been treated ethically by their teachers. These findings echo a growing body of work on the culture of medical teaching environments, often termed the "hidden curriculum," which emphasizes the profound influence of the culture of medicine on the behaviors of practicing physicians, because it shapes basic assumptions about what are "acceptable" and "unacceptable" medical practices (27). Haidet and Stein (28) list content examples from the culture of medicine that contradict professionalism and ethics training. For example, the hidden curriculum often sends a message that "it is okay to be rude when you are doing something really important," implying to students that "outcome is more important than premise."
This study has four limitations: First, the possibility of sample bias, that is, residents who were more positive about training in ethics and professionalism may have been more likely to take the survey, but it should be noted that the high response rate somewhat mitigates this concern. Second, the survey asked respondents questions hypothetically; responses might have been more optimal had questions asked about "real-life" clinical situations or settings. Third, the survey measured noncognitive variables and is thus subject to response bias or response set. We would expect these limitations to skew our results toward more positive attitudes about ethics training, its goals, learning methods, and curricula. Finally, the study did not explore whether receiving such ethics educational interventions translated to actually improving the competency of residents to deal with such dilemmas.
Psychiatry residents continue to value ethics and professionalism curricula and see the goals of such education as being firmly aligned with their clinical practice, helping them with patient care and clinical decision-making. Furthermore, role-modeling of ethical reasoning by faculty and team case-based discussions about ethics were more favorably viewed as learning methods over more individualized approaches. Educators should endeavor to incorporate these strategies into curricula. Educators should be encouraged that psychiatry residents perceive an increased amount of training in this area, as compared with previous studies; however, psychiatry residents continue to face a moderate degree of ethical challenges in their training. This represents an area for continued study. The actual ethics approaches that should be used to create such curricula, which ethical dilemmas residents find most important to discuss (e.g., understanding about conflicts of interest when doing psychiatric research versus involuntarily hospitalizing patients), the degree to which they should be examined and to what extent the nature of such discussions should be dependent upon theory, instructor perspective, or classroom discussion all warrant further investigation and delineation.
Completed Suicide: Resident Psychiatrist Reflection
Horrified by Iraq,
He returned with fear and guilt,
Faced a crumbled marriage,
Withdrew from sons.
His ultiamte answer was suicide.
No note, no explanation,
As an intern,
I'd never had a patient die.
Despite hours of talking with him,
I still wonder why,
Perhaps if he had forgiven himself,
He might still be alive.
Kimberly Bentley Steiner, M.D., B.S.E. PGY2 Psychiatry
The authors thank Scott Helberg, M.S.; Ann Tennier, B.S.; and Katherine A. Green Hammond, Ph.D., for their assistance in the preparation of this manuscript, and Robert Jarvis, M.D., for assistance in data collection. Mr. Helberg, Ms. Tennier, and Dr. Roberts received funding through the Research for a Healthier Tomorrow-Program Development Fund, a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin.
Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer-review, applied to all manuscripts. Also, the editor is recused from any editorial decision-making.