Ethics Skills Lab Experience for Surgery Interns
Margaret Moon, MD, MPH; Erin L. McDonald, MPP;
Mark T. Hughes, MD, MA; Joseph A. Carrese, MD, MPH
Johns Hopkins Berman Institute of Bioethics, Program on Ethics in Clinical Practice
ETHICS SKILLS LAB
- Surgery residents encounter important ethics issues in routine clinical practice.
- Competent surgical care requires skills in identifying and resolving ethical challenges.
- Beyond didactic learning, surgery residents need experiential learning to develop and practice relevant skills.
- We describe the development and implementation of ethics skills labs for surgery residents.
- Adapting ethics education to a format already familiar to surgical interns led to a productive and engaging educational experience.
- Through faculty facilitated small group discussion, surgery interns were able to develop models for ethical practice that paralleled established models.
- Skills based training in ethics was well received by surgical interns.
- A marker of success is that the Program Director for the Surgical Residency has requested that this program be offered again to new interns.
1. Residents discussed experiences with delivering bad news and obtaining informed consent:
- Knowledge and attitudes presented
- Positive and negative experiences described
- Role of faculty and senior residents in modeling skills discussed
2. Faculty facilitated small group discussion to generate frameworks for appropriate practice:
Delivering Bad News: Interns developed ideas about appropriate and inappropriate interactions when delivering bad news.
- Group consensus was organized into framework for practice.
- Framework was then compared to “SPIKES” algorithm for delivering bad news
Setting appropriate for discussion
Patient’s perceptions clarified
Invitation to discuss news
Strategy / Summary of next steps
Informed Consent: Interns developed consensus framework for meaningful informed consent.
- Framework was then compared to ethics model of informed consent with key domains of:
Consensus frameworks developed through group discussion closely approximated the established models for both delivering bad news and obtaining meaningful informed consent.
3. Simulated Patient Experience:
Case involving new diagnosis of breast cancer was developed in consultation with Dept. of Surgery faculty.
Role for simulated patient was developed in consultation with Dept. of Surgery and the Simulation Center.
Checklists of appropriate skills when delivering bad news and obtaining informed consentwere distributed to interns to be used while observing simulated patient interactions. Checklists were compared to the consensus frameworks created by the interns.
Case: 33 year old single mother with family history of lung cancer and a new diagnosis of stage 1 ductal carcinoma of the breast. Initially noted on self breast exam; confirmed by mammography. Biopsy occurred 2 weeks ago. Options for surgery include radical mastectomy or lumpectomy with radiation.
2 simulated patient scenarios:
- Intern charged with delivering news of diagnosis and establishing strategy for moving forward.
- Intern charged with obtaining meaningful informed consent based on patient’s preferences regarding surgical approach.Options for radical mastectomy vs. lumpectomy with radiation were understood to be equivalent with respect to survival.
- Each lab session included 2 performances of each scenario. While one intern interacted with the simulated patient, colleagues observed and evaluated the interaction based on the observation checklists.
- After simulated patient encounter, intern in role play reflected on experience with group and ethics faculty to reinforce teaching points.
- Constructive criticism was offered by colleagues based on observation guide.
- Simulated patient offered specific feedback to interns based on each encounter.
- Setting: Department of Surgery devoted a set of ongoing surgical skills training lab sessions to ethics skills development for interns.
- Objective: Using a one-time 3 hour interactive small group lab experience, interns obtain education and practice in delivering bad news and obtaining meaningful informed consent.
- Format: 4 sessions occurred in Spring 2008, 24 interns participated in groups of 4-6. The components of the educational experience included:
- Open discussion of current experience
- Mentored small group discussion with didactic component
- Simulated patient experience
- Ethics education that adapts to program-specific structures and educational styles may be better received and may be more likely to succeed.
- This exercise in skills training impacts directly on the core competencies of:
- interpersonal and communication
- Morton K. and Jane Blaustein Foundation
- Freeman Family Scholars Program
- Johns Hopkins Berman Institute of Bioethics