Today's psychiatric residents must learn their craft—and continue to work—within increasingly complex and challenging healthcare and social environments. During training, residents embark on what will be a lifelong process of learning and honing their attitudes and skills related to ethics and professionalism. These include identifying, clarifying, and managing ethical tensions in clinical and other settings (e.g., assessing a patient's decision-making capacity); operationalizing broad principles of ethics and professionalism, including faithfully serving, with justice, honesty, and integrity, the interests of patients; and caring for vulnerable populations (e.g., abused children, victims of domestic violence, or terminally ill patients). It is understood that the development of these core skills and values related to ethics and professionalism is critical, but there is uncertainty about the adequacy of current training for psychiatry residents in these areas.
In a 1996 multisite study (1), substantial percentages of the 181 psychiatric-resident respondents reported wanting more formal curricular attention paid to areas such as understanding the legal rights of patients with compromised decisional capacity (73%); obtaining informed consent from psychotic patients for medical/surgical procedures (62%); administration of psychotropic medications and admission to a locked facility (60%); and knowing when to report a patient case to Child Protective Services (43%). Since this study was conducted, postgraduate training has undergone an important transition—namely, the institution of competency requirements in professionalism (2, 3) for residents and the development of ethics and professionalism curricula designed to meet these requirements (4—7).
More recent work (8) has shown that psychiatric residents express stronger interest, in general, in having more ethics training and enhanced education directed toward ethics problems during training (9) than their colleagues in other specialties. These findings were limited, however, by the use of a convenience sample of trainees at a single site.
Ethics and professionalism topics and principles represent overarching, integral aspects of psychiatric practice that affect the daily lives of residents. Later, their daily lives as psychiatrists—in practice, as teachers training the next generation of psychiatrists, and as researchers and leaders—will also be deeply affected by their understanding and operationalization of these principles. Residents' views of their training are therefore critical to evaluating the current state of education in these areas.
There has been no recent multisite assessment of the educational needs of psychiatric residents in the key ethics topics of informed consent, professional principles, and treatment of vulnerable populations Although it could be argued that trainees do not necessarily "know what they do not know," residents in previous studies have expressed opinions about the degree to which many topics in ethics and professionalism were being addressed (1, 8, 9). We therefore conducted a comprehensive multisite survey of psychiatry residents that focused, among other areas (10—12), on the need for education in informed consent, professional principles, and treatment of vulnerable populations.
On the basis of previous studies (1, 8, 9, 13), we hypothesized that residents would continue to perceive a need for curricular attention to such areas.
All psychiatric residents in postgraduate years (PGY) 1 to 6 (N=249) at seven training programs in Spring 2005 were invited to participate in this study. The seven sites were chosen for convenient sampling and to represent a range of psychiatric training settings. The sites 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, 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 (8, 9, 13). The original instrument contained 124 content items organized by 10 domains, which were derived from the American Board of Internal Medicine (ABIM) definition of professionalism (2): 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 each rated on 9-point scales, which were scaled from 1: Much Less, to 5: Same, to 9: Much More education desired. For the current study, 28 additional questions relevant to psychiatric residency training were added. The revised instrument contained 149 questions in the 10 content domains, 6 questions regarding personal ethics experiences during training, and 5 demographic questions. Here, we report findings concerning educational needs for informed-consent topics, principles, and care of vulnerable populations.
The survey was distributed to psychiatric 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 to all psychiatric residents 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.
For each set of related topics, 9-point scaled rating responses were subjected to repeated-measures Education Item (within-subjects repeated measures) × School (between subjects) × Gender (between subjects) MANOVAs. We examined correlations among education items and the six questions regarding personal ethics experiences during training.
A total of 151 psychiatric residents from seven medical schools participated in the survey; response rates varied from 51% to 77% across schools, with an overall response rate of 61%. Residents were at PGY-1 training level (13%), PGY-2 (21%), PGY-3 (30%), PGY-4 (23%), and PGY-5 or -6 (13%). 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% were African American; 4% were Asian American; and 4% were of other or unreported ethnicity. Ethnic composition varied among schools (p<0.01), from 47% to 93% white, from 0% to 47% African American, and from 0% to 19% Asian American. Mean (standard deviation [SD]) age was 31.1 (4.4) years. Residents had encountered ethical conflicts to a moderate degree during training (mean: 5.16, on a scale of 1: Never to 9: Constantly). 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).
Educational Needs on Topics Related to Informed Consent
As seen in Table 1, psychiatric residents indicated that nine topics related to informed consent should receive more educational attention than was provided at the time (means: 5.91 to 6.66, scaled from 1: Much Less, to 5: Same, to 9: Much More). Residents indicated that conducting assessments of decision-making capacity, obtaining informed refusal from patients who decline recommended treatment, obtaining informed consent from patients whose decisional capacity is compromised, and obtaining informed consent or refusal from surrogate decision-makers should receive more attention (means: 6.41 to 6.66) and indicated that obtaining informed consent from non—English-speaking patients; deciding when to withhold information from patients; discussing risks, benefits, and alternatives to the recommended treatment with patients; deciding how much clinical information to share with patients; and obtaining informed consent from patients who are capable of making decisions should receive somewhat more attention (means: 5.91 to 6.24; Topic Item main effect F[8, 130]=9.30; p<0.0001, maximum Cohen's δ=0.53). The rated amount of additional attention needed for informed-consent topics overall varied among the seven medical schools represented in the survey (means: 5.73 to 6.68; School main effect F[6, 137]=3.27; p<0.01; maximum δ=0.70). The pattern of additional attention needed for specific topics varied across schools (Item x School interaction F[48, 644]=1.66; p<0.01), with the widest variation for conducting assessments of decision-making capacity (means: 5.40 to 7.54; maximum δ=1.58; p<0.02, by Fisher's least significant difference). Higher ratings of additional educational attention needed were associated with more reported ethical conflicts encountered during training for 7 of the 9 informed-consent topics (r: 0.18 to 0.29; mean r: 0.22; all p<0.03).
TABLE 1.Educational Attention Needed on Topics Related to Informed Consent (N=151)
Educational Needs on Issues Surrounding Principles of Ethics and Professionalism
As seen in Table 2, psychiatric residents indicated that 10 issues surrounding principles should receive more educational attention than now provided (means: 5.76 to 6.06, scaled from 1: Much Less, to 5: Same, to 9: Much More): compassion for suffering, respect for human dignity, responsibility to improve community, faithfully serving patient interests, respecting patient autonomy, nondiscrimination, justice, truth-telling and honesty, scientific integrity and research, and respecting the law. Higher ratings for additional educational attention needed were associated with more reported ethical conflicts encountered during training on 8 of 10 issues surrounding principles (r=0.17 to 0.32; mean r: 0.22; all p<0.04).
TABLE 2.Educational Attention Needed on Issues Surrounding Ethics and Professionalism Principles (N=151)
Educational Needs on Care of Vulnerable Populations
As seen in Table 3, psychiatric residents indicated that 25 topics related to the care of vulnerable populations should receive more educational attention than was provided at the time (means: 5.46 to 6.57, scaled from 1: Much Less, to 5: Same, to 9: Much More). Respondents indicated that the most additional attention should be provided for care of abused children, patients with HIV, situations of domestic violence, terminally ill patients, people with infectious diseases with public health consequences, and care of pregnant patients (means: 6.35 to 6.57); some additional attention to care of patients from other cultures, non—English-speaking patients, prisoners of war/combatant detainees, patients with mental illness, indigent patients, violent patients, elderly people, patients with critical illness, adolescents, patients with chronic illness, military personnel, children, patients in rural areas, employees, patients who abuse substances, people at risk for genetic disorders, suicidal patients, and women (means: 5.86 to 6.30); and the least additional attention to care of men (mean: 5.46; Item main effect F[24, 114]=7.20; p<0.0001; maximum δ=0.75). The rated amount of additional attention needed for care of vulnerable populations overall varied among the medical schools represented in the survey (means: 5.45 to 6.73; School main effect F[6, 137]=3.49; p<0.01; maximum δ=0.90). The pattern of additional attention needed for specific topics varied across schools (Item x School interaction F[144, 674]=1.32; p<0.01; δ=0.56 to 1.43 for single items). Higher ratings for additional educational attention needed were associated with more reported ethical conflicts encountered during training for 21 of 25 vulnerable population categories (r=0.17 to 0.32; mean r: 0.23; all p<0.04).
TABLE 3.Educational Attention Needed on Issues Surrounding Care of Vulnerable Populations (N=151)
Collectively, our data support our hypothesis that psychiatric residents desire heightened curricular attention to numerous topics related to ethics and professionalism. These topics spanned a broad range of issues related to informed consent, refusal of treatment, and care of vulnerable patients.
Although every item related to informed consent was rated as needing more attention in the curriculum, topics rated as needing the most attention were conducting decision-making capacity assessments, obtaining informed refusal from patients who decline recommended treatment, obtaining informed consent from patients with compromised decisional capacity, and obtaining informed consent or refusal from surrogate decision-makers.
The problematic aspects of obtaining informed consent have been previously highlighted in a study that surveyed 108 psychiatric residents from New York City. Residents' ability to obtain informed consent was assessed by presenting them with three hypothetical clinical vignettes. Only 3% of residents met the criteria for obtaining adequate informed consent, and only 1% met criteria for obtaining optimal informed consent. The poor results were attributed to a failure to initiate informed consent, not necessarily secondary to a lack of knowledge, and the authors concluded that the residents had limited understanding of informed consent as an active process (14). Other reasons why trainees may be less likely to engage in adequate informed consent were secondary to uncertain knowledge and authority, lack of experience, and susceptibility to influence by supervisors (15). Clearly, psychiatric trainees in this sample continued to recognize ethical challenges related to informed consent during training and desired more educational attention in this particular topic, despite their endorsement of the statement that current educational needs were being met to a significant degree.
Those who reported experiencing more ethical conflicts during residency were more likely to endorse a need for more education. For example, higher rates for additional educational attention needed for seven of the nine informed-consent topics were associated with residents' also reporting more ethical conflicts encountered during training. The value trainees place on ethics education as a way of understanding and resolving dilemmas has been demonstrated elsewhere, and the replication in this study should serve as additional encouragement to psychiatric educators (8—10, 13).
Residents also perceived a need for more education on bioethical principles, with compassion for suffering, respect for human dignity, and responsibility to improve the community deemed most important. Interestingly, all three items relate to the humanistic aspects of caring. In recent years, teaching the humanistic aspects of care to medical trainees has been emphasized more. One study recommended specific teaching methods, such as taking advantage of seminal events, role-modeling, and using active learning skills (16). Another author proposed using "humanism connoisseurs"—physicians who are able to be both professional and humanistic and have effective teaching skills, as model teachers (17). Other studies assessing the perspectives of preclinical medical students highlighted faculty and peer role-modeling, bedside teaching, and student reflection on inner experience as preferred methods of learning about professionalism and humanism in medicine (18).
Residents reported considerable need for more curricular attention on dealing with complex ethical, social, philosophical, and legal issues surrounding the care of vulnerable populations, especially abused children, patients with HIV, victims of domestic violence, terminally ill patients, people with infectious diseases with public health consequences, and pregnant patients. This perceived need is perhaps reflected on a national level with growing federal efforts to define, track, and address disparities in quality of healthcare among different racial, ethnic, and socioeconomic groups in the United States (19).
This study has several limitations. Even though the study was conducted at multiple sites, results may not be generalizable; as in all survey studies, the respondents may represent those with stronger views, such as residents with greater interest in the topics surveyed. However, the relatively high response rate helps mitigate such a bias. Another limitation is that the study surveyed psychiatric residents' preferences and experiences on particular topics in ethics education and professionalism, but the study was not designed to explore individual differences or personal factors that account for the variations in responses. Nevertheless, the study provides insights into trainees' perceived needs in the vital educational areas of ethics and professionalism.
Today's psychiatric residents work in an increasingly complex, highly fragmented medical care environment, where patients and clinicians alike face many hurdles toward achieving optimal care. Residency should ideally provide a time for trainees to acquire a firm understanding of the principles that guide complex decision-making in challenging environments and to learn, practice, and gain confidence in their abilities to handle difficult ethical and professional situations. This study suggests that greater attention to numerous topics in ethics and professionalism is needed. Educators should thus continue to devote curricular attention to these areas and enhance training related to topics in ethics and professionalism.
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.
At the time of submission, the authors reported no competing interests.