Microsoft Word - 15 Journal of Medical Ethics and History of Medicine Biomedical ethics teachings to postgraduate doctors Yasmin Wajahat Sobhraj Maternity Hospital, Pakistan. *Corresponding author: Yasmin Wajahat Address: Sobhraj Maternity Hospital, Pakistan E-mail: ywajahat@gmail.com Received: 30 May 2009 Accepted: 01 Aug 2009 Published: 19 Aug 2009 J Med Ethics Hist Med. 2009; 2:15. © 2009 Yasmin Wajahat; licensee Tehran Univ. Med. Sci. Introduction Postgraduates programs in bioethics are avail- able globally in Canada, USA, Australia, UK, Europe and now with the efforts of UNESCO across much of Asia including India, China and Japan (1). In Islamic Republic of Pakistan, the first formal move in introducing bioethics teachings in the medical students’ curriculum was made at Aga Khan University, Karachi in 1984. It was in 1997 that workshops and courses focused on local ethical dilemmas were made mandatory for the postgra- duate clinical training of the residents at AKU (2). Pakistan Medical and Dental Council (PMDC) in 2001 stipulated that bioethics must be included in the medical curriculum (3). The Centre for Bio- medical Ethics and Culture was established at the Sindh Institute of Urology and Transplantation in 2004 and began the Postgraduate Diploma Course in Bioethics in 2006 (4). Informal postgraduate teaching of bioethics is conducted in different institutions at Karachi and also by Karachi Bioeth- ics Group (formed in 2004). This platform allows postgraduates, residents and faculty to educate themselves about emerging bioethical issues through discussions (5). A bioethics curriculum for postgraduates has been implemented at Sobhraj Maternity Hospital (SMH) from January 2007. SMH is a public sector hospital, located centrally in Karachi, Pakistan. On average, approximately 200 patients are seen daily in the outpatient department. The various problems faced by the doctors are busy outpatient department leading to overcrowding, shortage of staff with one doctor dealing with forty patients and lack of general resources. Due to this scenario, various ethical concerns that arise include issues of patient-physician relationship, truth telling, privacy, confidentiality, disclosure and informed consent. Hence there is a great need for training of the postgraduates in biomedical ethics so that they can carry out their clinical practice in an ethical manner. This paper highlights the experience of teach- ing biomedical ethics to postgraduate trainees for Membership of College of Physicians and Surge- ons (MCPS), Pakistan examinations, who come for two years training and doctors who come for their six month internship in Obstetrics & Gynecology specialty to SMH. Discussion As biomedical ethics education is a mandatory discipline globally, this intervention of teaching postgraduates is required to build capacity in ethical reasoning skills of young doctors. This would assist them to resolve everyday conflicts and enable them to relate global issues in terms of our own traditions, religious, and socio-cultural norms. Such concerns include issues of beginning of life, brain death, persistent vegetative state (PVS), organ donation and end of life care / palliative care. Teaching program in bioethics was initiated at SMH in January 2007. At the outset, the curricu- lum was designed for six months but it took more time as it was planned. Currently we are in the third J Med Ethics Hist Med 2009, 2:15 Yasmin Wajahat Page 2 of 3 (page number not for citation purposes) round of teaching which began in September 2008. The topics discussed include privacy and confiden- tiality, maintaining physician patient relationship, euthanasia and aspects related to reproductive health such as miscarriage, prenatal diagnosis, surrogacy and ovum donation. Teaching methodology incorporates class- room, interactive discussions done in large groups, and bedside small group discussion. The classroom sessions are conducted twice a month, each lasting for an hour. Bedside teaching is done during clinical rounds. This makes four to five rounds each month. Bedside teaching helps in both, practical oriented learning as well as in overcoming the time constraints faced, as these sessions have to be scheduled along with the postgraduate training. Several activities are implemented to sensitize the students and engage them in discussion. Presentations are made by students on topics selected from UNESCO textbook “A Cross- Cultural Introduction to Bioethics” and from chapters on ethical dilemmas, given in the text book of Obstetrics & Gynecology. These presenta- tions are followed by a question & answer session. Reading and discussion of articles from local newspapers constitutes a learning activity. This creates the ability of critical thinking amongst trainees. Executing role plays on given scenarios, for example taking informed consent and watching and analyzing movie clips for ethical issues, contributes to learning, complimented with recreation. Another classroom activity was the compila- tion of a glossary by students. Initially, a list of selected words was distributed amongst the students. They add new words, which they come across and find related to the subject of bioethics, to this list. Written assignments also constitute an important part of the class activities. They help the students to share their opinions regarding the given topic; for e.g. “Is it ethical for doctors to receive gifts from pharmaceutical companies?” In addition to this, in order to analyze the understanding of trainees, a small question related to the subject was added to the monthly obstetrics & gynecology test, which helped them to learn the simple definitions and critical writing. Bedside teaching during clinical rounds is also incorporated in the teaching methodology. This gives the trainees on ground opportunity to implement what they learn during class, for example, to maintain privacy during the discourse with the new patients, developing the skills of communication to establish a good patient- physician relationship and to develop the skill of taking informed consent from the women patients undergoing surgery. For ensuring respect for patients, all trainees were required to involve the patient in the disclosure and comprehension and make sure that a consent form was duly filled and signed, first by the patient herself and then by her spouse or guardians. This was perhaps the most difficult aspect in a male dominated society where consent from women is not regarded important. Most of the women patients were not willing to take the initiative themselves and left the responsi- bility of giving consent to their spouse or guar- dians. Initiation of this teaching program was rela- tively easy because of the seniority level of the trainer in the hospital and support of Medical Superintendent. However, managing the program as decided was slightly tricky and challenging. One of the major issues was the inconsistency of following the planned topics as the trainees were on rotation basis for specific periods; therefore, certain topics had to be repeated with the entry and exit of trainees. Also, the planned topics were not followed as sequenced when current issues were added in the discussion. Another obstacle was changing mindsets of trainees. It was not easy to stress on the application of concepts that had been excluded from previous education especially at undergraduate level in medical education. However, exposure to biomedi- cal ethics education made the trainees think differently and look for solutions to ethical problems in their clinical practice. Conclusion The feedback was obtained from the trainees and according to them, “these sessions have opened new concepts and enabled them to think abundant- ly”. Now, textbooks of Obstetrics & Gynecology also include chapters on biomedical ethics, which add to the interest of the trainees. A larger number of postgraduate diploma holders in bioethics are also available to train the younger doctors. Moreo- ver trainees, who continue to work in the hospital, after clearing their MCPS exam having a previous exposure to bioethics teachings, serve as an additional hand to guide the junior trainees in dealing with ethical issues. Although it is a two years short experience, a more positive outcome can be expected in future. A conscious effort is still required as ethical practice may be neglected during emergency situations. J Med Ethics Hist Med 2009, 2:15 Yasmin Wajahat Page 3 of 3 (page number not for citation purposes) References 1. Anonymous. Abstracts of presented papers at the Eighth Asian Bioethics Conference (ABC 2007). Eubios J Asian Int Bioeth 2007; 17(3): 65-96. http://www.eubios.info/EJAIB52007.pdf (accessed on Jul 2009) 2.Ahmed A. Country Report: Pakistan. Indian Council of Medical Research. 2006, http://icmr.nic.in/bioethics/cc_biothics/presentations/int_chennai/CR_Pakistan.pdf (accessed on Jul 2009) 3. Moazam F, Jafarey A. 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