Microsoft Word - 7 Journal of Medical Ethics and History of Medicine       Medical ethics course for undergraduate medical students: a needs  assessment study   Fariba Asghari1, Aniseh Samadi2, Arash Rashidian3 1Associate Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; 2Researcher, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran; 3Professor, Department of Health Management and Economics, School of Public Health and Institute of Public Health Research, and Center for Academic and Health Policy, Tehran University of Medical Sciences, Tehran, Iran.     Corresponding Author: Fariba Asghari Address: Medical Ethics and History of Medicine Research Center, #21, Shanzdah Azar St.Tehran, Iran Email: fasghari@tums.ac.ir Tel: 98 21 66 41 96 61 Fax: 98 21 66 41 96 61 Received: 23 Jan 2013 Accepted: 22 Jun 2013 Published: 05 Aug 2013 J Med Ethics Hist Med, 2013, 6:7 http://journals.tums.ac.ir/abs/23708 © 2013 Fariba Asghari et al.; licensee Tehran Univ. Med. Sci. Abstract Education  needs  assessment  is  one  of  the  essential  components  of  curriculum  development.  In  this  study,  we  aimed to assess the educational needs of general physicians for medical ethics.  We conducted a three‐stage Delphi study of general physicians’ views on important ethical issues in their practice.  In the  item generation stage we retrieved 45  important educational  items from a survey of general physicians,  patients, well known ethical clinicians, and a review of other universities’ curricula and international literature. The  questionnaire was designed to ask the  importance of each generated  item. We then sent the questionnaire to  general physicians. Items scored as highly important by more than 80% of the respondents in the first or second  consensus development surveys were considered as educational priorities. Four academic medical ethics teachers  reviewed and commented on the findings.  The  response  rate  to  the  first  consensus  development  survey  was  38%,  of  whom  77%  also  responded  to  the  second survey. We developed consensus on 24 medical ethics items for inclusion in medical ethics curriculum. All  items were also considered important by medical ethics teachers, and they added four further items to the list.  Despite the attention given to ethical issues originating from technological advances, the most important educa‐ tional needs of general physicians in medical ethics are still the traditional  issues concerning the doctor‐patient  relationship and professionalism.    Keywords: Needs assessment, Medical ethics education, Delphi method, General practitioners J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 2 of 7 (page number not for citation purposes)     Introduction Medical ethics is a core component of medical education intended to empower practitioners in ethical decision making (1); it is in light of its importance that the contents and the teaching methodology of the course are constantly criticized and reviewed (2,3). Linking education with the needs of the society is an important prerequisite for effective education. Otherwise it may become impossible to achieve the goals of education, and this can lead to a waste of human and financial resources. Educational needs assessment is the process of determining the gaps between the required competencies of trainees and the reality (4) and it is an essential part of curricu- lum development (5). Educational needs assess- ment is even more important in designing curricula for subjects such as medical ethics in which the cultural and religious underpinnings of the society should be reflected. In recent years, different methods of needs as- sessment have been used to identify the needs of medical students and residents in terms of medical ethics and professional behaviour. In some ap- proaches, students are asked to rank the importance of a number of professional ethics issues (6,7). In others, students are assessed in their ability to make ethical judgments when confronted with common issues in practice (8,9). Results of such studies have pointed to different needs that vary by medical specialty and by society. Medical ethics syllabus in Iran had initially been developed based on expert opinion. In Tehran University of Medical Sciences, content revision of the medical ethics course was made in 2006 using a review of literature and expert opinions (10), although its validity was not examined by needs of general practitioners. In this study we assessed the views of general physicians on their educational needs in medical ethics. We aimed to identify those medical ethics topics that should be included in the undergraduate medical education curriculum. Method Design The Delphi method is a useful approach for developing consensus among a relatively large number of participants (11) and has been used extensively for the purpose of developing educa- tional programmes (12-15). We conducted a three- stage Delphi study (item generation plus two consensus development surveys) and complement- ed the findings with expert opinions. Figure 1 demonstrates the general outline of the study. Participants For two reasons we selected our participants from general physicians: firstly because they have completed the medical education programme and are familiar with the medical ethics course con- tents, and secondly because they are more likely to offer realistic arguments concerning the importance and necessity of incorporating different medical ethics topics in the curriculum since they are practicing medicine. We approached the attendees of a national con- tinuing medical education (CME) conference and distributed announcements about the study among them. The said conference is one of the largest in Iran covering about 50 half-day CME events in all specialties. One hundred and thirty six general physicians volunteered to participate. Item Generation We used five different approaches for the gener- ation of items for inclusion in our consensus development exercise: 1. We sent a letter to the 136 general physicians volunteering for participation in the study. It contained one open-ended question: “Consider- ing your practice experience, please state the most common medical ethics issues that you have encountered during your professional ca- reer.” We also enclosed the purpose and meth- ods of the study and sent a reminder after one month. 2. Four clinical academics known as role models for their consideration of ethical issues in prac- tice were interviewed. They were asked to ex- press their opinions of a general physician’s needs in terms of medical ethics. 3. Patients attending two general physician clinics in Tehran (one in the north, one in the south, 5 patients each) were interviewed about their expectations from their physicians. Eight items related to medical ethics were extracted from their responses. 4. We reviewed the syllabi of the medical ethics courses of Shiraz and Isfahan universities of medical sciences. 5. Based on the literature, we assessed a review of medical ethics training in North American uni- versities (16), a study of the agreement between the lecturers of medical ethics and law in the UK (17), and a study of designing the core course of medical ethics in Australian universi- ties (18). We extracted 29 individual items from respons- es to the letter. Thirteen items were extracted from interviews with clinical academics, eight items from interviews with patients, nine items from review of other universities’ curricula, and ten items from literature review. Several items overlapped and ultimately a list of 45 issues in medical ethics was included in our questionnaire (Table 1). J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 3 of 7 (page number not for citation purposes)     Consensus Development In our first consensus development survey, we sent the questionnaire to 136 general physicians and asked them to score the importance of each item on a 1-9 scale (1 indicating low importance, 9 indicating high importance) for inclusion in the medical ethics curriculum. We sent a reminder with a copy of the questionnaire after two months. The second survey questionnaire included 31 items for which no agreement was reached in the first survey. We also reported to the participants which items had already reached the consensus level. This questionnaire was sent exclusively to the respondents of the first survey (52 people) (Figure 1). For each respondent we presented the score they had given to the 31 items, and the relative frequency of other respondents’ views on the importance of the items. We then asked them to re-score the importance of each item after taking others’ views into consideration. We also asked for their comments on the scores they assigned to each item. We sent two reminders each after one month. Analysis and Measuring Consensus To analyze the scores given to each item, we classified the responses into three categories: low importance (scores 1-3), medium importance (scores 4-6), and high importance (scores 7-9). We also calculated the median score for each item. ‘Reaching consensus’ was defined as having 80% agreement on any level of importance and was calculated for each item separately. All analysis criteria were set a priori (19). Expert Opinion While reviewing the responses and comments given to the second survey, we noticed that some physicians had commented on their agreement with certain behaviours relevant to the item, and not on their agreement on whether the item should be covered as part of the medical ethics curriculum. For example, instead of commenting on the importance of teaching the item “truthfulness towards the patient and their families”, they had expressed their opinion on whether truthfulness should be observed in poor prognosis conditions or not. Table 1. Items developed in the item generation stage and included in the questionnaire  No. Item No. Item 1.   Ethics in teaching medical students 24. Fairness among patients 2.   Ethics in research 25. Referral to qualified physicians when necessary 3.   New advances in assisted reproductive technology (IVF, embryo donation, egg donation) 26. Conflict of interest (advertising or prescribing particular medications) 4.   Confronting end of life issues and do not resuscitate orders 27. Conflict of interest (accepting gifts from patients or industry) 5.   Ethical dealing with lab animals 28. Conflict of interest (high fees, fee splitting) 6.   Constructive interaction with media 29. Adherence to religious beliefs and moral values 7.   Doctor-patient responsibilities 30. Avoiding waste of public resources 8.   Role of family in completing the diagnosis and treatment process 31. Telling the truth to patients and their families 9.   Respect for patient’s privacy 32. Admitting to own medical error 10. Respecting patients’ religious and cultural beliefs 33. Disclosing peers’ errors 11. Dealing with requests for inappropriate treatment 34. Relationship with other members of health care team (nurses, etc.) 12. Making efforts to relieve patients’ pain 35. Relationship with peers 13. Obtaining informed consent 36. Visiting peers free of charge 14. Abortion 37. Confidentiality of patient data 15. Maintaining respect for the profession by physicians 38. Use of unnecessary or expensive diagnostic tests 16. Practitioners’ personal appearance and grooming 39. Confronting difficult patients 17. Dealing with unethical requests 40. Respect for patient autonomy, and involving them in decision making 18. Knowledge of theoretical foundations of ethics and philosophy 41. Responsibility for treatments administered to the patient 19. Thorough completion of patient records 42. Complete history taking and clinical examinations 20. Knowledge of different insurance policies 43. Allocating enough time to each patient 21. Knowledge of and respect for the law 44. Appropriate relationship with patients 22. Accountability when on call 45. Issuing false certificates 23. Commitment to updating scientific knowledge IVF=in vitro fertilization J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 4 of 7 (page number not for citation purposes)     To overcome this limitation, we assessed the views and opinions of medical ethics teachers about the Delphi results. For this purpose, we sent the first survey questionnaire to four academic medical ethics teachers, and asked them to score each item. After collecting their responses, we sent them the collated views of the general physicians and asked them to state their reasons for scoring items differently where applicable. Results Forty three (32%) physicians participated in item generation. The questionnaire for the first survey was sent out to all 136 volunteers, and 52 (38%) responded. We sent the second survey questionnaire to the 52 respondents, of whom 39 (75%) responded. 59% of the participants were male, their mean age was 38 ± 6 years, and their practice experience was 9 ± 4 years. Table 1 reports the results of the item generation stage. In the first consensus development survey, we observed consensus on the importance of 14 items. The participants achieved consensus for a further ten items in the second round (Table 2). Items with the least importance were ethical dealing with lab animals and constructive interac- tion with media with a median score of 5 each. Compared with general physicians, the medical ethics teachers had significantly different opinions on the importance of four items. Adding the items to those already reported in Table 2 provided us with 28 items for inclusion in medical ethics teaching curriculum (Table 3). Table 2. Items with consensus on high level of importance No. Item Percentage of respondents who scored items in these categories Median score (1-9) High (7-9) Interme- diate (4-6) Low (1-3) Items with consensus after the 1st consensus development survey (14 items) 1 Appropriate relationship with patients 90 4 6 9 2 Allocating enough time to each patient 86 8 6 9 3 Complete history taking and clinical examinations 84 10 6 9 4 Relationship with peers 80 18 2 7 5 Confidentiality 90 8 2 9 6 Adherence to religious beliefs and moral values 82 16 2 8 7 Referral to qualified physicians when necessary 82 18 0 8 8 Commitment to updating the scientific knowledge 82 16 2 9 9 Responsibility for treatments administered to the patient 86 14 0 9 10 Accountability when on call 80 18 2 9 11 Knowledge of and respect for the law 90 10 0 9 12 Maintaining respect for the profession by physicians 86 12 2 9 13 Doctor-patient responsibilities 82 14 4 9 14 Ethics in teaching medical students 85 13 2 9 Items with consensus after the 2nd consensus development survey (10 items) 15 Respecting patients’ religious and cultural beliefs 82 15 3 8 16 Relationship with other members of the health care team (nurses, pharmacists, etc.) 87 13 3 8 17 Telling the truth to patients and their families 82 18 0 8 18 Thorough completion of patient records 85 10 5 8 19 Making efforts to relieve patients’ pain 85 15 0 9 20 Dealing with requests for inappropriate treatment 90 10 0 8 21 Respect for patient’s privacy 85 15 0 8 22 Knowledge of different insurance policies 82 18 0 8 23 Obtaining informed consent 80 20 0 8 24 Fairness among patients 80 17 3 8 Discussion The results of our study present us with a list of 28 important items that need to be taught to medical students. The participants reached consen- sus on the educational importance of 24 items. According to our results, ethics priorities for general physicians are not brought about by modern technology or advances in medicine (e.g. reproductive health issues); basically they are the same items that have long been among ethical commitments or challenges of physicians. These items require physicians to take on the role of a healer and maintain an ethical approach that gives priority to patient needs rather than their ability to perform complicated ethical analysis on current ethical dilemmas. J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 5 of 7 (page number not for citation purposes)     Contrary to our expectations, there was a con- flict of opinion on the importance of “respect for autonomy and involving patients in decision making”. This is while participating patients in the item generation phase of the study had clearly indicated that they expected such respect from physicians. The study by Asghari et al. also showed that patients preferred to receive information and be involved in decision making (20). Reviewing practitioners’ comments on this item suggested the predominance of a paternalistic approach towards doctor-patient relationship among them. One physician stated, “The patient must thoroughly and completely follow the orders of his/her doctor. The patient’s knowledge of the chosen treatment modality is too limited to give them the option of autonomy”. The medical ethics teachers, however, disagreed with this view and found the item important. Table 3. Academic medical ethics teachers’ and general physicians’ opinions on selected items Item % of physicians scoring the item highly important Median score given by physicians Median score given by senior lecturers Medical ethics teachers’ opinion Respect for patient autonomy, and involving them in decision making 62 6 8 It seems general practitioners do not believe in this right for patients, but it is very essential. Conflict of interest (high fees, fee splitting) 66 7 8 Unfortunately, they happen so often, that they seem very natural to do. Issues on doctor- patient conflict of interest are common and are damaging the reputation of physicians. Use of unnecessary or expensive diagnostic tests 69 7 8 Due to a lack of adequate insurance coverage in our country, this issue is rather important Confronting difficult patients 32 6 8 Although it is not as important as previously mentioned items, in current medical practice there are many difficult patients Two years ago, major amendments were made to the entirety of the medical ethics curriculum in Iran (10). Comparing the results of our study with the pre-amendment content of the course showed that 7 sessions (out of a total of 15 sessions) were not in accordance with the essential needs of general physicians. Nonetheless, our results indicate that the course contents may need to be re- addressed. After the amendments, this was reduced to 4 out of 17 issues, such as abortion, end of life issues, ethics in research and resource allocation. Some items belonged more in the legal realm than in ethics (Knowledge of different insurance policies, Knowledge of and respect for the law), which in our curriculum are not included. We plan to negotiate with the Forensic Medicine Depart- ment about covering these two items in forensic medicine and medical law course. Although the results of our study did not indi- cate the need for resource allocation for General practitioners, their giving high scores to the item of “Fairness among patients” might mean that they need resource allocation to be discussed at the micro level. In 1998, teachers of medical ethics and law in medical schools throughout the UK offered their consensus statement about the medical ethics curriculum (17), and in 2010 they updated their statement (21). Compared to their recommenda- tions, we found 5 of the 12 topics were relatively unimportant in the clinical practice of general physicians in Iran; these include research, fertility, genetics, death and termination of life, resource allocation, mental disorders and disabilities (21). In comparison with the consensus statement of teachers of ethics and law in Australian and New Zealand medical schools regarding the educational content, again six topics were detected unimportant in our survey: research ethics, reproductive ethics, issues in genetics and biotechnology, ethical issues in commercialization of medicine, resource allocation and end of life decisions (18). In a survey of ethics education at U.S. and Ca- nadian medical schools, end of life issues and allocation of scarce resources were taught in 92 and 75 percent of medical schools respectively. Surprisingly about half of them did not cover genetic tests, reproductive technologies, abortion, research ethics and medical error (16). Our study has some limitations. Physicians’ scorings for educational purposes can be biased by their belief in a given ethical issue as demonstrated earlier by discussing patient autonomy. We used the comments raised by medical ethics teachers to J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 6 of 7 (page number not for citation purposes)     minimize this potential source of bias. Another limitation is the extent to which we can generalize our findings. Random sampling is not required in the Delphi method if the participating individuals have enough expertise (or experience) to provide a balanced judgment. Nonetheless, considering the variety of general physicians’ services and the recipient populations, it may seem more appropri- ate to have a representation of the total population of general physicians. Random selection from all general practitioners was not feasible, and we believed ethical issues encountered in Tehran would not be significantly different from those in other provinces, yet a more extended study would give a more accurate understanding of physicians’ educational needs throughout the nation. We also received a relatively low response rate. It has been shown that the topic of a survey affects response rate (22) and hence we expected to receive more responses as the participants were volunteers. Still our response rates were similar to many surveys of physicians around the world (23,24). Our results can be informative for designing courses in other developing and Islamic countries. Our search did not reveal any published study from Islamic countries using similar methods for assessing medical ethics educational needs. Revising course contents based on learner needs is only the first step for enhancing the learning process and educational outcomes (i.e. improving physician behaviour). Change in course content will enhance the outcomes only if effective educational methods are used (25). Medical ethics courses should be continuously assessed in terms of their contents, educational methods and change in behaviour, and revised in light of the results of such studies. Figure 1. Flowchart demonstrating the study process Item generation stage  1 st  round of consensus  development  Response rate=38%  (n=52)  Sample selection Medical ethics teachers’  opinions  Results  Volunteer general physicians  attending the CME event   Open ended question about  the most common ethical  issues encountered  Patients’ opinions  Clinical academics’ opinions  Review of course curriculum  in other universities  Scoring the importance of 45  items on 1‐9 scales   2 nd round of consensus  development  Response rate=75%  (n=39)   Scoring the importance of 31  items on 1‐9 scales    J Med Ethics Hist Med 6:7 June, 2013 jmehm.tums.ac.ir Fariba Asghari et al. Page 7 of 7 (page number not for citation purposes)     Conflict of Interests: none Funding: According to contract number 132/7941, this study was funded by Tehran University of Medical Sciences. Acknowledgements We thank all physicians who participated in our study. 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