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D evelopment of Moral Reasoning during Medical Education

D evelopment of Moral Reasoning during Medical Education. Darko Hren, PhD Croatian Medical Journal and University of Split Croatia. Moral reasoning (Neo -Kohlbergiann approach). P. POSTCONVENTIONAL

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D evelopment of Moral Reasoning during Medical Education

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  1. Development of Moral Reasoningduring Medical Education Darko Hren, PhD Croatian Medical Journal and University of Split Croatia

  2. Moral reasoning(Neo-Kohlbergiann approach) P • POSTCONVENTIONAL • Administration of moral ideals in a fully reciprocal way so that each member of society has an equal status • Adhering to ideals • Generalizable ideals • Primacy of moral ideals MN • MAINTAINING NORMS • Taking a broader societal perspective through adherence to norms, regulations and laws. • Need for norms • Broader societal viewpoint • Uniform and categorical application of norms 3 developmental schemae PI • PERSONAL INTEREST • What each protagonist of a moral dilemma (or their significant other) has to gain or lose? • Personal gain is the main issue • Includes only immediate surrounding

  3. DEVELOPMENT OF MORAL REASONING DURING HIGHER EDUCATION Cross sectional studies:Rest (1979) – formal education explained 50% of variance in scores on a test of moral reasoning Longitudinal studies:Rest & Deemer (1986) – attending college explained 38% of variance in scores Educational orientation:Deemer (1987) – educational orientation explained 13% of variance in scores Review articles:King i Mayhew (2002) – more than 500 studies which addressed the issue of relationship between education and moral reasoning

  4. MORAL REASONING AND MEDICAL EDUCATION No gains in moral reasoning scores:Self et al,1993; Self & Baldwin, 1994;Morton, 1996; Self, Olivarez & Baldwin, 1998 Decline in scores:Patenaude et al, 2003

  5. AIM Investigate the relationship between moral reasoning and medical education

  6. INSTRUMENT DIT2 – Defining Issues Test (Rest et al, 1999) 5 short stories presenting a moral dilemma After deciding, participants rate 12 questions for importance in making a decision Scores for each schema (P, MN and PI) Developmental profiles (predominant schema)

  7. Times of measurement RESEARCH DESIGN Year ofenrolment 2002 2003 2004 1st yr.n=131 2004 2nd yr.n=139 • Controlsn=298 • Same age span(18-27) • Never studied 2003 3rd yr.n=153 2nd yr.n=207 Matchedn=61 2002 4th yr.n=101 2nd yr.n=192 Matchedn=75 2001 5th yr.n=85 2000 6th yr.n=77 1999

  8. RESULTS – AGE AND DIT2 SCORES Zero correlations between all DIT2 scores and age for both, medical students and controls

  9. SEX (M=0, F=1) RESULTS – SEX AND DIT2 SCORES (M=0, F=1) DIT2Scores P MN PI Med. Students 0.20* -0.12* -0.14* Controls 0.12* -0.04 -0.12*

  10. no stat. sig. differences P RESULTSScores of different generations of students at the same time point of their study MN PI Generations of students

  11. stat.sig. difference between groups of students (F5,679=3.67, p=0.003, η2=0.03) • stat. sig. quadratic trend (p=0.035) P RESULTSDifferencef between medical students on different study years • no stat. sig. differences (F5,679=0.83, p=0.527) MN • stat.sig. difference between groups of students (F5,679=3.38, p=0.005, η2=0.03) • stat. sig. reverse quadratic trend (p<0.001) PI Year of study

  12. stat. sig. interaction between repeated measurements and developmental profiles at the first measurement(F1,129=8,25, p<0,001, η2=0,11) P RESULTSChanges in scores over time • stat. sig. interaction between repeated measurements and developmental profiles at the first measurement(F1,129=12,58, p<0,001, η2=0,16) MN • stat. sig. interaction between repeated measurements and developmental profiles at the first measurement(F1,129=14,87, p<0,001, η2=0,19) PI GenerationIn=75 Generation IIn=61

  13. Medical students’ moral reasoning scores increase during preclinical years, but... CONCLUSIONS ...they decrease when students enter clinical rotations, but... • ...they do not decrease below Maintaining Norms schema.

  14. WHY?(a few speculations...) Clinical hierarchy Specific dilemmas which are not addressed Feudtner & Christiakis (1993): LEARNING vs. PATIENT CARE TEAM PLAYER vs. PERSONAL PRINCIPLES QUESTIONING ROUTINES vs. ABSOLUTE IGNORANCE PERSONAL KNOWLEDGE OF THE PATIENT vs. MEDICAL KNOWLEDGE Hidden curriculum ...

  15. WHAT CAN BE DONE? Small group case discussions specific issues as early as possible at least 20 hours (Self et al, 1998) vertical approach related to students’ experiences (critical incidents discussions)

  16. WHAT ELSE? Social learning – teachers, mentors, elders, superiors... Hidden curriculum – research, awareness, direction Investigate all components which lead to moral behavior (moral sensitivity, moral reasoning, moral motivation, moral character), develop and evaluate interventions

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