Living Ethics: Teaching Across the Continuum of Medical Education

Hello everyone thank you so much for joining us uh today for our Health Professions educator health system science open form session we have Dr Sarah dwit presenting for us today um and are super excited to hear what she has to to bring forward for us Dr dwit is a physician in paliative care and emergency medicine with clian Clinic she's also the program director for hospice and paliative Medicine Fellowship an is an assistant professor in the Departments of internal medicine Health Systems and implementation science and emergency medicine as well as the elective director for paliative medicine just want to note to you uh please feel free to add any questions that you may have in the chat and we will be checking for those throughout Dr Whit I'm gonna or Dr DT I'm going to go ahead and uh turn this over to you thank you Sarah um welcome everybody thank you for joining us um hope everyone was able to log in okay we were all kind of having some login issues with zoom today um a special shout out to Dr olendorf Who gave me the idea of the of the title for this talk um I really appreciate that I was having a hard time figuring out a title so living ethics um because this is something that we live with every day and and deal with every day as we'll kind of talk through a little bit more today um any time if you guys have any questions um or you know have anything you wanted to add please don't hesitate to to raise your hand um or add something into the chat box and I think that's going to be monitored um as well okay next slide please so our objectives for the day um we can't start an Ethics discussion without at least reviewing the basics of ethics and describe the pillars of medical ethics um we're going to talk a lot about the impact of values professional ethics um legal responsibilities on decision-making and Health Care Systems we're going to talk about the process of ethical decision- making and a critical setting and really focus a lot of our time on identifying opportunities to incorporate education surrounding medical ethics in your clinical practice um on a day-to-day level next slide please um we also can't talk about health system science and ethics without bringing in our wonderful um health system science wheel so this is something that we all know and love and I think um in the red there you can see that um ethics and legal aspect of medicine play a huge role in health system science um and we're going to talk a lot today about how common ethical issues are really on a day-to-day basis for probably most practitioners whether or not you something you are consciously aware of um these are some issues that that absolutely come up every day um definitely in my world and I think a lot in in medicine in general next slide please oops we have our polls are you guys going to we're going to have some polling um if you guys can answer these um and then we'll kind of see where everyone stands give you guys a few more seconds to answer and then Deb whenever you're ready can pull up the results of those all right let's end the poll and see what we have thank you okay can everyone see the results of that so I was curious you know how often do you feel you encounter ethical issues in your clinical practice 59% of people said um some of the time and 41% said daily um medical students interact with have a good understanding of ethical issues that arise in clinical practice um we're kind of split here almost 5050 53% said no and 47% said yes and then residents and fellows I work with are able to recognize analyze and navigate ethical issues in clinical practice um I like to see that 100% of people said some of the time so at least they there's some of the time recognizing these ethical issues um my my hope you know after several years of in residency and also in medical school that these numbers will start to increase as well okay next slide please so let's review briefly medical ethics and the principles of medical ethics um I feel we can't really have a discussion on how to teach medical ethics um until we kind of just have a basic review of the medical ethical principles that we encounter every day um so the four main principles of medical ethics are autonomy beneficence non-maleficence and Justice um there's a school of thought that say there's six um pillars um some people say four plus two regardless of of of how we kind of categorize these other two dignity is really important and honesty or or what's known as veracity is another element or another common principle of medical ethics that we should talk about and we're going to briefly go through each of these individually next slide please so beneficence you know this is the ordinary meaning of the principle that Healthcare Providers have a duty to be of benefit to the patient so we need to act in the best interest of our patients do good for our patients and advocate for the good of our patients non-maleficence is that premium no no that our duty to do no harm um I think it's important to note that really anything in medicine whether it's um just even a lab test or it's it's a medication or major surgery there's always going to be burdens of of a treatment option there's always going to be risks associated with treatment there's always going to be side effects of medications or or treatments that we offer and we should really on a on a moment by moment and day-by-day basis be weighing the benefits of these treatments versus the harm that we know are inevitable in some things that we do um and so I think n maleficence we need to really you know really focus on part of non maleficence is really focusing on not offering care to patients that are really more harmful than beneficial and that can get really hard especially nearing the end of life um part of non-maleficence is also this obligation to protect those patients who are at risk for abuse or neglect next slide please um the right or the the principle of autonomy this is the right to self-determination I get to decide what what happens to me um I get to choose my medical care and so the idea of is nothing to for or concerning a person against their will um we're going to talk a little bit about the historical impact um of several cases um in you know in the 70s and 80s and 90s that really impacted autonomy and really made it a main focus really of American Medical system um we have a right to determine what happens to ourselves part of autonomy is also this idea of capacity versus competency you know one one's a a medical term capacity one's a Le legal term competency um it's important to also talk about substituted judgment and surrogate decision- making when patients lack competency or lack capacity and then informed consent is a really important part of autonomy we can't expect our patients to make decisions for their care or for their loved ones care if they don't have all the information they need to make an informed decision so informed consent is a is a is a topic that comes up when we start really talking about autonomy next slide please and then justice justice is a really important um uh pillar of medical ethics it really came up in the covid pandemic this is the idea of to do the most good for the greatest number of people and that all individuals are entitled to comparable resources and benefits including access to care treatments and protections when we were worried about scarce resources you know we were talking a lot about how do we allocate scarce resources how do we determine who gets this precious resource whether it's a ventilator or an ECMO or you know the covid vaccine when it first came out and how are we prioritizing who got those first um so Justice really really came to the forfront in in the medical ethics world and really in really the medical world during the covid pandemic so it's important to think about next slide please and then veracity and respect for dignity so it goes without saying that we um are obligated to uphold confidentiality for our patients um we are obligated and we should tell the truth to our patients we should be honest in their prognosis And discussing treatment options and discussing what is likely to happen to them we also have an obligation to not abandon our patients and we'll talk a little bit about this in a little bit where this really comes up and obviously we should um always respect our patients emotions their relationships their reasonable goals privacy and bodily Integrity next please I like this slide I use this a lot in a lot of my um educational Endeavors regarding ethics um because it's really important to know that not one pillar or principle really outweighs the other and in any given ethical situation any given medical situation there might not be one right answer there might be multiple different options and it's our job to as providers as clinicians as Educators to really way discuss and balance the priority between these different principles that sometimes are are in conflict with each other right your patient who's you know becomes a protesting patient um who lacks capacity but clearly doesn't want this one thing to happen to them what do we do with that um sometimes you know these these principles aren't always in sync and they're not always on the same page um and sometimes as I mentioned there's not one great answer rather there's there's a possibility of answers and it's our job to find the best answer for our patient at that time I'm going to briefly review um whenever I talk about ethics whether it's to the medical students or to um residents or fellows I think it's important to review the AMA American Medical Association code of ethics um and I'm going to briefly go through this so if I talk really fast it's just because I've given this a lot and I've I've I've said these nine princip or these nine codes of Ethics uh very frequently but it's important to remember that we you know we we made an oath and whether or not we agree with what the AMA says I think these principles hold true a a physician shall be dedicated to providing competent Medical Care with compassion and respect we shall uphold the standards of professionalism be honest in all of our professional interactions and strive to report Physicians deficient in character or competence we shall respect the law and also recognize your responsibility to seek changes to those requirements which are contrary to the best interests of the patient we shall respect the rights of our patients our colleagues and other healthc Care Professionals and S shall always Safeguard patient confidences and privacy within the constraints of the law obviously next slide please we shall continue to study and Advance scientific knowledge um and maintain a commitment to Medical Education we should be free to choose whom to serve with whom to associate and the environment in which we want to provide medical care or Practice Medical Care we shall recognize the responsibility to participate in activities that contribute to the betterment of our communities and we shall while caring for patients regard responsibility of the patient is Paramount and we should shall support access to medical care for all people so a nice reminder of some of the things that we should be doing on a day-to-day basis and I think all of us do strive to to Really follow these codes there has been several uh Landmark historical cases that really exemplify some issues in medical ethics and really you know have led us to where we are today in terms of why we prioritize certain things over the others and again I'm going to just briefly talk through these uh because I don't want this to be the main topic of our conversation but I think it's important to recognize that there have been several really important landmark cases um that have guided us and have changed medical ethics and and kind of changed how we treat patients and the recommendations that that we make to them so the first case um the first right to Die case was Karen quinland I hope you guys have probably all heard of of Karen quinland in 1975 that she was in a persistent vegetative state out after a motor vehicle accident um she her parents after a period of time I think it was just a several weeks um wish to allow her to die naturally and the doctors refused stating that removal of life sustaining measures was the equivalent of murder and so you have to think back so 1975 was only 30 30 40 50 years ago really not that long ago whereas in today's standards we know that patients have a right to choose their medical care their surrogate decision makers have a right to withhold or withdraw life sustaining treatments but 50 years ago this was considered murder then it went to the New Jersey Supreme Court where the court found that families and surrogate decision makers um could use quality Life as a legitimate factor in making decisions regarding the withhold withholding or withdrawing of life sustaining measures um interestingly she ended up Surviving um so so her parents wanted to take her off of life support So ventilator um she ended up Surviving about 10 years off of mechanical ventilation but she did receive artificial nutrition and hydration next slide please so in 1983 this was the first case um Nancy cruising case was the first case to get all the way up to the Supreme Court and um she was in a persistent vegetative state oh I'm sorry she was the one that was thrown from her vehicle um quinland was the one that was at a party and became unresponsive um Nancy cruzin was thrown from her vehicle and she received um resuscitation and she was in a persistent vegetative state that required artificial nutrition via a peg tube um after several years her parents requested that her feeding to be removed um and the hospital um refused this went all the way to the Supreme court and where they gave and they found that we have a fundamental natural right to refuse or direct the withholding or withdrawing of artificial life prolonging procedures when a person has no more cognitive brain function and is there's no Ro hope for further recovery and then um not even 10 years later I think we've all heard of the Terry shyo case in the 90s this was a really prolonged case for several reasons um Terry shyo suffered a cardiac arrest there's likely thoughts that it was due to some complications from her um bulimia um although that's there's some discussion regarding that her husband and her family sought treatment for her for eight years eight years they took her from place to place to try to get neurological Improvement after eight years it was found that she wasn't really improving at all and she was in a vegetative state her husband requested that her G2 be removed because he did not feel she would want to be alive um in the state that she was in it took two years for the courts to agree in another 5 years years um in which her parents appealed um but this was a case that really highlighted the different moral views different moral views of different moral of different religious communities and just different ideas of thought regarding artificial nutrition and hydration um ultimately she was allowed to die die peacefully all right I'm GNA stop there for just a second and see if anybody has any questions so far okay and again please feel free to interrupt me at any time if anybody has any questions we're small enough Sarah I was thinking um it when you gave the first two cases I was thinking the pendulum has swung now right to where um I think uh healthc care teams are trying to convince families to withdraw fair in certain situations um as opposed to at least the first case um so do you see that a lot more or was it just the cases that you provided happen to be yeah I think it's it's it's a combination I think there are certain cases where providers are now recognizing when care is medically or ethically inappropriate to Contin life sustaining care would be maybe medically inappropriate and they are pushing families when in that case to you know making strong recommendations for the withholding and withdrawal of life sustaining measures um I think that you know there's a lot of fear of that um there's a lot of fear for providers to make those strong recommendations there's a lot of fear for family to receive that information um because I don't know if there's a lot of trust you know there's a breakdown of trust in the in the healthare system um in the medical care system and I think a lot of times when you hear of stories whether it's in the media or personal stories from family or friends um or acquaintances they're and and they're saying oh you know the the providers are really pushing for us to stop care to to really stop life sustaining care um there's usually like a negative connotation with that and so you know I don't know where the breakdown lies but I think it's a combination of hopefully it's medical providers making strong recommendations that are medically appropriate so if it is medically appropriate to withhold or withdraw life sustaining measures hopefully they're making those recommendations and hopefully there's enough Trust on the family side to to hear to hear what those medical recommendations are it is incredibly tough um T but I know there's a lot of backing behind the decisions that are made um there's a couple of questions in the chat if you want to take a minute to answer them yeah let me find the chat sorry um got it all right Dr olander I would like your opinion on how obj meets the a code of ethics and respects the law that affects access to reproductive health care for their patients and can cause that can cause them harm that's a great question um and one I don't think I have not read exactly the am's opinion so the AMA publishes their official opinions and they have a list of them um in regards to a number of ethical issues I will after this if anybody or if anybody's interested to to Google it um they can try to find if there is a formal opinion by the am I do know the AMA has historically been very conservative and so hot topics um particularly regarding reproductive health or transgender care might not be given an opinion um in fact the AMA only recently came out with an opinion within the last four years regarding physician Aid and dying um before four years ago their opinion was that it was morally unacceptable and now they have a stance of neutrality so the AMA is always a little bit delayed in and when they come out with their recommendations or their opinions um and Dr schner wrote where's the AMA in terms of patient advocacy today it's a good question I think I think they have their own priorities um and depending on you know the topic at hand um I think you know love them or hate them they're they're an organization that that are probably funded by just like you know politicians um and there are certain things that are probably more important to them than others um like I said though they've been a little bit delayed especially in some of the big social issues of the day um I know physician Aid and dying well just because that's something you know that that's relevant to my clinical practice um so I can I can really speak on that but the other two I don't I can't really speak on fully what their what their opinion stance is on that all right so let's talk about why ethics is really important in clinical practice today um in order for it to be important to teach to teach our medical students our residents and our fellows I think we all have to recognize that it's important in everyday clinical practice and I would argue that I know most people said that they sometimes deal with um ethical issues I would argue that we probably deal with it on a day-to-day basis we probably just don't recognize it for what it is um next slide please here's a list of some likely scenarios that come up um that could come up on a day-to-day B basis right what if a patient refuses treatment any treatment simple as antibiotics or they refuse your recommendation to change life lifestyle or they refuse to stop smoking or they refuse life sustaining measures what if a healthare decision goes against a patient's cultural belief what if a member of the healthcare team makes a life-threatening mistake what if a healthcare decision goes against your own as a as a physician your own cultural beliefs what if your minor patient is diagnosed with pregnancy or STI so I think you know and these are just some some really brief examples but I think it's important to think there are ethical questions that rise probably every day all the way from OBG to medicine to peeds um and from a workplace even even if you're not seeing clinical patients clinically from a workplace there's there's you know there's there's institutional ethics there's there's lots of ethical issues that arise just from an Institutional perspective as well next slide please so since ancient Greece and the Hippocratic Oath was created Physicians have been held accountable for taking care of their patients and ensuring little or no harm to them comes the concept of of a code of ethics that lays out guidelines for Physicians professional conduct and their ethical obligations has remained relevant in the healthcare field ever since the rapid development of medical techniques treatments and knowledge following World War II um culminated in the creation of several core ethical principles that are still used today in medical field to guide ethical decision-making and patient care and those are the ones we really reviewed earlier next slide please oops one one back um Healthcare professionals honestly face ethical d every day with advances in medical technology and increasingly diverse patient populations the industry's need for Clear ethical guidelines is more critical than ever um these ethical issues in healthcare can be challenging and for a lot of people whether it's from the your nurse or or your support staff or even you as a physician this can lead to moral distress right doing something to people that is against our ethical standards or our own moral standards can lead to really moral distress um Healthcare Providers prioritize patient well-being which can sometimes mean respecting patients wishes that they may disagree with so we're not always going to agree with the decisions our patients or their surrogates make next slide please so for our patients all the ethical principles um benefit patients because it guarantees respect for patient autonomy and Equitable treatment um and it guarantees that patients will receive the best care available based on their beliefs and their decisions this also builds trust and allows patients to trust their Healthcare practitioners without reservation and this can be really important especially when you're talking about really you know when when we're at a Crossroads when treatment or no treatment will make a huge differ in someone's health and well wellbeing next slide please for practitioners we know that there are situations where we might run into ethical disagreements with our patients with families with caregivers with even other staff members other other practitioners um and we with with you know an ethical guideline we we can we can recommend a solution that places patients care first having guidelines also um to support one's decision allows for one's conscious to remain clear and ethics will help dictate what the best decision should be for the ideal outcome knowing that there might not always be the most perfect answer there usually is a combination of right answers by having an ethical framework that encompasses the entire uh facility healthcare workers can feel assur that their co-workers are operating at the same intent as they are and it allows for easier communication between workers fewer misunderstandings and a greater sense of mutual trust ethical guidelines can help practitioners find the least obtrusive and most beneficial solution to a patient's issues available reducing the chance of risky or or unnecessary procedures and treatments and the idea of non-maleficence extends to patients and colleagues in the healthcare field right Healthcare professionals can feel their workplace is safe and administration can work to mitigate and alleviate stress as much as possible so some um some things to think about um and kind of to summarize ethics and Healthcare is what guides the work of Professionals in the healthcare industry these considerations are an essential component of providing health care and um as they help ensure practitioners treat their patients with dignity and respect and that decisions are made that are made by Healthcare professionals are fair and just and ethics can help promote trust and confidence in the Healthcare System slide please so two things to just think about these are some kind of big ethical issues um that that I get questioned a lot about when especially with Learners so what happens when the legal system is at odds with medical ethics right this is a big one in our society today um and I quote the AMA just because that they are you know just easy to quote and they they have a whole thing on medical ethics and and I I I do um I do believe in what they say here a physician shall respect the law and also recognize the responsibility to seek changes to those requirements which are contrary to the best interest of the patient I think we need to remember that we have an ethical obligation to fight some of these things that we might that that ethically and medically are not appropriate um especially in different states in things you are seeing every day I think Dr olendorf made a mention of that second thing is um next slide please what happens when our own personal beliefs get in the way of patient care this is something to really think about I think it's important because we all have to recognize that we have our own biases we have our own beliefs and our own moral values and we need to recognize that we have a duty to our patients and that Duty should come first we might not always agree with the decisions our patients make we might not always agree with what they want for their care but we have a duty to help them we have a duty to respect their decisions and we have a duty to not abandon them in their time of need so the AMA gave an opinion piece said this and I just want to briefly read this preserving opportunity for Physicians to act or to refrain from acting in accordance with um the dictates of their own conscience is important for preserving the Integrity of medical profession as well as the Integrity of the individual physician however Physician's freedom to act according to their own conscious is not unlimited they are expected to provide care and emergencies honor patients in formed decisions to refuse life sustaining treatment and respect basic civil liberties and not discriminate against patients on the basis of arbitrary characteristics next slide please so let's get to kind of the meat of the discussion I know that was a big a big overview and and a big um talk about medical ethics in general um as you can tell I can probably talk about this for for a long time um and um I kind of want to talk next about how why it's important in medical education and how can we best deliver this information to medical students all of our residents all of our fellows every learner that we have come through U because this should not just be left up to you know medical school to teach them the basics of Ethics this is something that we need to constantly continue to build upon on every level of Education in the medical um Continuum next slide please so um from a requirement perspective there are requirements from the lcme and the acgme that Learners at all levels receive instructions addressing professional formation to prep to prepare them for a lifelong commitment to professionalism and patient care educational research this is this is ethics a physician's ability and willingness to act in accordance with accepted Norm um moral norms and values is one key component of professional behavior um and there are educational objectives relating to ethics um that are now often incorporated into broader goals for professional education next slide please so the lcme um that kind of governs all undergraduate medical education they specify that students behavior must be observed and assessed to ensure that it is in line with acceptable acceptable ethical guidelines it's kind of vague and I know they're moving a lot more towards milestones and epos um but they are they are expected to receive education on ethics and to be measured and observed in a assessed on that the acgme um feels that it's so important that it's one of the six core competencies for all acgme um specifically focusing on professionalism stating residents must demonstrate a commitment to carrying out professional responsibilities and and an adherence to ethical principles they're expected to show compassion and respect for others put patients needs above their own respect patients autonomy act accountably and demonstrate sensitivity to patients from diverse backgrounds next slide please so we know that it's important to teach ethics now how do we best deliver this content to our to our students next you just click it um we do this by cultivating behaviors that exemplify ethical and professional virtues so in 2015 academic medicine actually um published the What's called the romanel report and it was it's probably you know it's one of the first of its kind it's it's a really well done report that an um it's an analysis of the current state of medical ethics education in the United States both at the undergraduate and The Graduate graduate uh medical education level and it proposed educational objectives that all medical students and residents should receive during their training so upon completion of medical school or residency training everyone should have an appropriate level of proficiency to demonstrate an understanding of the concept of the physician as a fiduciary and the historical development of medicine as a profession recognize ethical issues that may arise in the course of patient care utilize relevant ethics statements from professional associations to guide clinical ethics judgment and decision- making so think the choosing wisely campaigns um think critically and systemically through um ethical problems using bioethical principles and other tools of ethical analysis provide a reasoned account of professionally responsible management of ethical problems and act in accordance um with those judgments and articulate ethical reasoning to others coherently and respectfully we expect our Learners to come out doing this and I think we behoove it upon ourselves to maybe recognize that maybe we all don't do this as well as we should um and so we we might need to be better role models on a day-to-day basis next slide please um and I'll let you guys kind of review this because because it's very wordy um but there the report also um kind of in particular delved into specifics that they expect Learners to be able to to um objectively do at the end of of their education um including like confidentiality right shared decision- making between your patient and yourself um dealing with conflicts of interest researching um the limits of research and using humans um in human in in in subjects in research um managing challenging patients and families the use of social media religious and spirituality differences um all the way they talk about gifts so it's it's a really good read I I recommend you guys review that um next slide please so then how do we teach medical ethics and incorporate into the curriculum it should be intentional and it should include U medical ethics at all levels of training next slide please there's no it's important to remember there's no single best approach for teaching medical ethics and professionalism the layered approach is best so multiple times you know discussing it um also important to recognize and this is true for any curriculum that you develop learning styles and learning levels vary and it's important to Target um to to deliver you know what know what you're delivering and to Target that based on the learner level that you are targeting that at um teaching methods should also be varied and flexible and remember there's really no one siiz fits-all in anything related to medical education so I think the first step next slide please we all need to recognize that ethical issues arise every day in the practice of medicine despite your specialty despite your practice location there are a lot of ethical issues that arise in the outpatient setting that we didn't really hit upon um but that that happened every day and one of my colleagues Dr wanie um and I deliver an Ethics d tactics to the internal medicine third years every six weeks and she you know can we can talk a lot about you know the ethical issues that arise in any clinic setting um it doesn't even have to be Internal Medicine um but just recognizing that every day there are ethical issues that arise in clinical practice that's the first step and identifying those next slide please and then with using that whenever learner you have with you it's being intentional it's being intentional and talking about you know these issues that arise say you have a patient who and and I do this this bedside teaching case-based teaching every day we have Learners every day on our service and obviously in paliative care I do realize that we are probably deal with more ethical issues on a day-to-day basis than most people do most other Specialties but we are very intentional in how we teach we are very intentional in how we review a case and so a lot of times it's a simple as who is a Sate decision maker right and that goes back to your principle of autonomy so it's tying in your your your clinical whatever clinical problem you have and tying it into some of these ethical principles and that's probably usually actually easier to do than you think it is so again you go back to a patient who lacks capacity right then you have to talk about well who should be their decision maker sometimes the person who legally is their decision maker might not always be the person who should be making decisions but as with anything with ethics the law we have to balance that with the legal aspects of Medicine as well and every state is different in regards to this so often times we have a case that we're talking about surrogate decision- making and having to identify a decision maker that's an ethical issue sometimes that person who lacks capacity is refusing um care and it could be for one reason or another patient refusing an amputation but clearly doesn't have capacity to truly understand that they become a protesting patient how do we balance that patient's right to not Chop off their their exity you know with their maybe their s decision makers desire for their life to be prolonged no matter what and so these are ethical issues that actually come up on a day-to-day basis you have to kind of delve into you know what's important to that patient who knows them best and sometimes you have to even get ethics involved um so bedside teaching is a really important way of delivering ethics education um in the clinic setting you have a patient who's non-compliant I hate that word but they're labeled as non-compliant they don't follow any of your recommendations they stop coming to appointments um and they get to the point where you know they keep coming in and asking for things that are unreasonable you know how do you deal with a patient like that that that becomes an ethical issue right that's institutional ethics that comes into play what are your policies at work you still have a duty to help your patient um and to make strong recommendations you still have a your duty to treat them with respect and dignity regardless of the decisions they're making for their care or you have a patient who um becomes combative and um they have capacity but they become threatening in some way or shape or form now you have to balance your own safety with nonabandonment now there most institutions will support anybody if they feel threatened that they are automatically allowed to fire um a patient in that regard but it's important to think about because these might these might be things that come up both in the impatient and the outpatient setting these are these are ethical issues that arise there was a question in the chat I'm going to try to find it unless somebody can read it to me I can read it too if you'd like very practical question um from Dr har what is the current situation for obtaining an impatient or outpatient ethics referral is there a referral mechanism that is easy to trigger in Epic not in Epic no and they do that on purpose um but the way to do it is twofold um there is an Ethics there's always somebody on for ethics and you can use perfect serve for that if you don't have perfect serve then you just call the hospital operator and they'll get you in contact with whoever is holding the pag for ethics but they purposely don't do um a consult to ethics because they need that they need that conversation the the ethic the um people who do the the ethics consults need to know you know the situation they need to have a discussion about it because in order to give their their ethical opinion they need to um kind of have you know that one-on-one conversation this is Michael Hart I just wonder if that creates a artificial barrier though I and perhaps a survey would be the answer to this to find out how many clinical practitioners if faced with a ethical question um know to go to you the mechanism because I I I think that perhaps if there's a triggering mechanism in Epic it might be beneficial to open the doors for more potential referrals yeah that's a that's a great considerations absolutely um I know that a lot of people come to the Pala of care team to ask some ethical issues and help guide them some of the times and some the times we're able to help them with that um and sometimes we we do also recommend an eth a formal ethics evaluation um or consult um I will have to I don't know if anybody is on the Ethics Committee that's on this call who can speak a little bit more to those that practical nature of how to how to make that referral and how to make that that phone call um but that could be a barrier I do know for for um our residents and fellows it's part of their orientation how much they they pay attention and listen to I think they are given um information on how to console ethics if they have an ethical um issue arise but as far as you know physicians in general I don't know if it's part of any real orientation um that we get when we you know start working here there was another question there is uh Dean lman uh types thank you for this thoughtful presentation what opportunities are there for health system science Champions to point out how ethical principles are used in practice during medical student workships it's a great question I know myself um and Dr wanie we talked to the internal medicine um clerkships about ethics and we give if you click the next slide we give actually a formal dactic um that's Al case based um and so we've created um curriculum that's a combination of formal didactic casebase interact interactive um to really talk about ethical issues that are arising in their in their clerkship years in their clerkship days um because what I found is that I can tell them cases and a lot of my cases are actually very interesting and it does get them motivated to to participate and to listen you know and and to learn I think learning best happens when it's really relevant to what they're doing and so often times I can pull from them cases that they're currently working on or working with and patients that they're currently working with and we can identify really cool ethical issues and then talk through that um with the ethical framework and so that's that's something that we do part of health system science but thirdy year IM clerkship now the other clinical Champions kind of all have their own um Niche and interest in the health system science world and I know that they all give didactics in all the different clerkships um that are health system science related um now I would love to be able to give ethics lectures to to every single specialty and and didactic but I do know that they all come to me at some point in their IM group and then they also um formal another formal didactic that they get is in their first year block four there's a whole block or for ethics it's an 8we block that we really delve into the um ethical princip principles we delve in really as a case um case based study um small groups and it's facilitator L um we really student L but facilitator helped and and we walk through really really important cases ethical cases um in the topic at hand for that week and so they get eight weeks of Ethics in their first year for Block four then they get it um a little bit of Ethics when their third year um system session I give a system session for end of life care and obviously can't talk about end of Life Care without talking about ethical issues and so we give um another layered approach is we give a there's a small group session of section of that system session where we talk about ethical issues that arise at the end of life and then obviously in their I am third year clerkship and my hope is that more and more students will do their rotation their one of their elective rotations in their fourth year with me because again we talk really about ethical issues on a day-to-day basis and if they spend time with my fellow Fellowship um we have a one-year Fellowship for hospice and and we give um an ethic series really Dr Whitehead Phil Whitehead really leads this and she gives talks that are pretty Advanced we talk about Medical Aid and dying we talk about you know our own biases and how they how how it leads us to maybe make medical decisions um and we talk about um oh there's some other big ones that I can't really remember at the moment thanks those are some really sorry Sher for interrupting no you go right ahead I say those are some very robust opportunities you just described and I remember teaching ethics cases in preclinical and clinical curriculum and a couple of other medical schools and when you take it to that high standard and it's very deep and informative uh sometimes that lets everyone else feel like they're off the hook but the most powerful educational experience the students is will have was when they when they bring ethical principles to the point of care from people who aren't necessarily experts but can bring it to the point of care in a very convincing way with respect to we need to do this right now for this patient have shared decision- making or to have autonomy or what have you so looking through at the world through it ethics classes is something we'd like everyone every clinical educator to have so they can highlight these moments that occur in everyday practice um so that's why I start pondering what can we do on clerkships to kind of just weave it in and those who want to go deeper certainly can and should but to weave it into the everyday experienced at the point of care absolutely go ahead Dr yeah that was That's My Hope too is that one that we as clinicians and Educators can recognize that there are ethical issues that arise every single day probably for most of our patients and then in US recognizing it being able to verbally talk about it with our students on a momentto moment basis and bring it like into rounds and it doesn't have to take long and you don't have to be an expert in ethics to really recognize that there are ethical issues and my hope is with that layered approach we start really training up um our medical students and really our residents and our fellows to recognize that you know they are an important part of of the ethics wheelhouse and that a lot of the decisions that they make and their their their patients and their families make are really housed in in in ethics and what a teachable opportunity when those everyday situations occurs just to explicitly call it what it is this is an ethical issue that we see every day all of these things and I love how Dr aland dorf mentioned he weaves it into his ethic or he weaves in ethics into the OB student lecture about abortion um that he recently inherited but but there's so many things we have these sessioned all all the time about the importance all of these important things that the medical students and residents must learn about but you can't just keep adding more things on and on without taking anything else away so the it's so important to just weave it into the the teaching that and the learning that they get every day Amanda uh Anderson also mentions that there are many applications for ethics and simulation sessions so weaving that right in um they've done an EOL EOL simulations with nurse residents where they are presented with some ethical considerations I think that's a great opportunity they're learning something else the main main topic may not be ethics but there's ethical elements um similar to what they encounter every day excellent thank you great points folks thank you everyone absolutely and I think that's my hope is just to that we all you know recognize that that these are issues that come up every day that if we can recognize it then we can teach our students this our Learners this um and we can we can kind of weave it into just a normal you know our normal rounds I know that we teach our students and our Learners you know how to manage X Y or Z who's to say we can't add you know maybe one one once around or every other day an ethical dilemma or an ethical issue as they arise um just something to think about Sarah this is Michael Hart I just one quick question I put it in the chat box but I in full disclosure I've retired from Clinical medicine four years ago but I still I just gave like pediatric Grand rounds last month uh at corillian and as I was talking with some of my colleagues it's interesting because I just had a a very informal uh discussion with some of the senior practitioners and faculty there and one thing that I thought was interesting their frustration was and this is where came in the ethics one of the things one of the topics that came up was U over gender identity and transgender and some of the things that were being the the students were the The Faculty were frustrated by the fact that the students said oh no of course a 12-year-old should choose their sex and they said that the students were very much oh no it's it's it's whatever the 12-year-old wants you know we wouldn't let him get a tattoo or start smoking or we would it's gone from a mental health or you know kind of a gender dysphoria to this the frustration they had was that the medical students in the discussion group were completely in favor of the patient making the 12-year-old making their full decision I don't have that much experience as a pediatric GI doct but the the transgender experience that I had um when I took care of transgender uh it was all well it primarily was uh single moms and the investment to me in the three that I dealt with as as patients of mine the mother was much more invested in the gender change than the child was and I thought to the point where it was almost a Munch housing situation and that's you know you call it factitious it's not much I wasn't called anymore but I mean what I'm saying is those are Hot Topics that I think the faculty or expressed to me their frustration that they felt the students perception was that they needed sort of a 30,000 foot view perspective on you know you're okay with the 12-year-old choosing in fact our you know they're getting hormone therapy and we're complicit if in fact this is really a a deeper dive mental mental health issue the students didn't feel they needed psychological evaluation and um they so oh no they should be able to choose what gender they they want without any sort of judgment they viewed as a psychology or Psychiatry evaluation is being judgmental and I thought wow that's that's interesting how that's that's almost a generational change that's exactly what I was going to tell say is I think that some of these especially the big the Hot Topic issues um that are generational dependent on on how you know some different Generations view um you know these ethical dilemmas right I think that what we hope is especially in their first year because in their first year in their block four we do talk about transgender care as part of one of the cases um in regards to I think it's autonomy or beneficence or not maleficence I can't remember exactly which week we we add that in but you know our hope is that they're not just a blanket yes this patient should just get X Y or Z because they want it and my hope is that in you know talking about ethics and debating ethics that they are really able to sit and and come up with an ethical analysis surrounding that issue because it's not always it's not black and white nothing really in medicine or life is black and white they're not reflexively just saying yeah it's magnified in I would say Pediatrics and Obstetrics and I'm sure that those two disciplines you know whether Dr Dr lman gets a 14-y old who wants an abortion without parents consent those kinds of issues are really hot topic issues those those two disciplines not to say that medicine doesn't deal with those every single day but those are really hot topic issues that U I think having the access to expertise your expertise in the evaluation might really help absolutely and if you if anybody ever identifies an issue that they comes up in clinical practice when they're you know in regards to education and they're not they're kind of stuck on how to educate this group of students on something I'm happy to always like field field questions and answer things um especially from a non-clinical perspective if it's a clinical question obviously we have our wonderful ethics department and our and our clinical ethicist that that can help with that but I'm always happy to feel any questions non urgently about like how do we teach our students how to think critically how to do an ethical analysis um based on on the clinical situation at hand agree I think Dr ol's comments that their ethical decisions and every decision you make is absolutely absolutely spoton we may kind of be unaware of it but there's it's just a degree of how significant they are or not no say that as an obstetrician I mean everything we do in obstetric is Mom versus fetus everything we do um and I do and I do addiction so the question is what do I do you know I'm giving a medication to a mother for her benefit which may have an effect on the newborn absolutely that's an ethical dilemma right um every every procedure we do In Obstetrics um has that and it gets complicated with the legal either um but um you know I'm sure and there's a lot of situations where you may actually be forced your hand may be forced because of legal issues you know and that's a I don't en I don't envy your situation because if the mother's technically doing something harmful for her fetus then I'm sure you must wrestle with these issues all the time of when do I pull the trigger and bring in law enforcement it's it's got to be a tough day-to-day decision called harm reduction so we you know we you know we seek to find less harm I mean there's harm in you know lots of different things um yeah the Law Enforcement issue that's a whole another issue of you know the privacy of the relationship versus your duty to disclose and that's a legal issue and yeah I mean it's you know there's so many things we can talk about but Sarah you can regain control the conversation no that's fine I just think it's important you know that whenever you talk about ethics you do have to bring in the legal aspect of medicine as well because so many of the decisions that we make um sometimes unfortunately or fortunately depending on the situation um we Bound by the law in a lot of ways um and so they don't they don't they're not independent of each other they're definitely you no can I just add a very quick comment Sarah this is a good interchange that we've just had and I would just point out that students are bringing to medical school the sensibilities of their generation which has been pointed out and they very much need an ethical way of the ethical principles as a way to understand how does this apply to the care of patients they desperately need this and a whole lot of uh different issues that have become popular to discuss in society the the the level of discourse in those discussions is minim minimal it's not very rigorous it's not very academic uh it's more related to what identity do you want to have in terms of what side are you on in a given debate in our polarizing climate so we've got to bring students back from the that societal challenge that they have into the big middle that ethics provides because as I remember from my my uh first philosophy course in college I got it they're really asking me to to answer the question with another question okay I understand that now so ethics means a way of asking the right questions to get to a a better understanding of how you apply the principles and our students need this more than ever um to to to change their thinking from student head to doctor head it's really important My Hope Is with multi-layered approach you know and and getting them in their first year following up hopefully in their second year hitting it again hard in their clinical years um and then obviously we need to take it further and talk about you know graduate medical education the e gme and really hoping that every residency and fellowship really continues to reinforce these principles and this way of thinking um hopefully it continues to to to grow their minds and and how they how they discuss debate and consider these ethical issues absolutely the group conference thank you really terrific thank you next slide please so quickly just some lessons learned in the last few years of me putting together multiple different types of ulum together regarding ethics no one size fits all we have to tailor it to each traine level what I do for my fellows is vastly different for what I do for medical students um is even moderately different from what I do for residents um be varied in your approach to education especially with regards to ethics right we can't just do you know a case-based learning we do have to talk about the principles we have to talk about how to do an ethical analysis then we have to layer it with case based and what's relevant to them at the time um as I mentioned Learners of all levels like real life cases to discuss um multi-layer approach is best and if you get feedback on a session you give take it seriously but be cautious to change your curriculum based on a single data point and that's it very nice Sarah very nice thanks thanks for the discussion everybody um and as always if you guys have any questions or or feedback please feel free to to email me or give me a call.