Client - meeting - _____ - 1 Key findings of the survey into learning, teaching and assessment of medical ethics and law Dr. Karen Mattick & Prof. John Bligh

Background to the study Pond report (1987) addressed the question of ethics in medical education. Pond report (1987) addressed the question of ethics in medical education. Tomorrow’s Doctors (1993, 2003) recommended that ethics be included in the core medical curriculum Tomorrow’s Doctors (1993, 2003) recommended that ethics be included in the core medical curriculum Consensus Statement (1998), model core curriculum for teaching medical ethics and law. Consensus Statement (1998), model core curriculum for teaching medical ethics and law. More recently, both the BMA and the IME Governing Body recognised need for more up-to-date information about the status of undergraduate ethics teaching More recently, both the BMA and the IME Governing Body recognised need for more up-to-date information about the status of undergraduate ethics teaching

Aim of study To determine whether the recommendations of the Consensus Statement published seven years ago had been implemented. To determine whether the recommendations of the Consensus Statement published seven years ago had been implemented. To characterise UK undergraduate medical ethics curricula To characterise UK undergraduate medical ethics curricula To identify opportunities and threats on the horizon To identify opportunities and threats on the horizon

Methodology Postal questionnaire survey on the undergraduate ethics and law curriculum sent to the lead in teaching and learning at each UK medical school Postal questionnaire survey on the undergraduate ethics and law curriculum sent to the lead in teaching and learning at each UK medical school Questions included design, teaching, assessment, staffing, and individuals’ hopes and concerns for the future Questions included design, teaching, assessment, staffing, and individuals’ hopes and concerns for the future reminders reinforced the importance of the study reminders reinforced the importance of the study Descriptive statistics used to describe some quantitative aspects Descriptive statistics used to describe some quantitative aspects Thematic analysis of the open-ended responses performed to identify important issues Thematic analysis of the open-ended responses performed to identify important issues Specific identifying information within quotes removed Specific identifying information within quotes removed

Findings: what to present today? Aims of the talk Aims of the talk  to provide information from the survey that is complimentary to the two manuscripts  to prompt discussions about future developments within the conference Structure of the talk Structure of the talk  overview of key findings  focus on areas of concern, presenting more ‘raw data’ than you will see elsewhere

Key findings

Overview of key findings (1) Completed responses from 22 / 28 schools (79%). Completed responses from 22 / 28 schools (79%). Significant changes identified that could be directly attributed to the Consensus Statement. Significant changes identified that could be directly attributed to the Consensus Statement. Most schools did cover all 12 recommended topics Most schools did cover all 12 recommended topics But only 3 felt they were covered thoroughly And 3 did not cover one or more topics at all Only 16 schools identified one or more full time academic that took direct responsibility for ensuring undergraduate medical students learnt about ethics Only 16 schools identified one or more full time academic that took direct responsibility for ensuring undergraduate medical students learnt about ethics These were usually at a lecturer grade. More information in: Mattick & Bligh Undergraduate ethics teaching: revisiting the Consensus Statement. In press, Medical Education

Overview of key findings (2) Aims for ethics teaching were successful (17 respondents, 77%) Aims for ethics teaching were successful (17 respondents, 77%) Ethics should be learnt throughout the course (20, 91%) Ethics should be learnt throughout the course (20, 91%) Ethics teaching and learning should be fully integrated horizontally (13, 59%) Ethics teaching and learning should be fully integrated horizontally (13, 59%) Variety in assessment was important (20, 91%) and 3 tools was the preferred number Variety in assessment was important (20, 91%) and 3 tools was the preferred number A shortfall in ethics core competencies did not preclude graduation (15, 68%) A shortfall in ethics core competencies did not preclude graduation (15, 68%)

Overview of key findings (3) Most successful aspects of courses: their integrated nature (10), the small group teaching (4) Most successful aspects of courses: their integrated nature (10), the small group teaching (4) Weaknesses: need still greater integration (6), the heavily theoretical aspects (5) Weaknesses: need still greater integration (6), the heavily theoretical aspects (5) Major concerns for the future: staffing and staff development (12, 55%) Major concerns for the future: staffing and staff development (12, 55%) More information in: Mattick & Bligh Teaching and assessing medical ethics: where are we now? Journal of Medical Ethics 32,

Areas of concern

Concern 1: staffing The concern: Staffing and staff development The concern: Staffing and staff development Generally, a small number of dedicated ethics teachers (e.g.1-3) plus a much larger number of sessional tutors. Generally, a small number of dedicated ethics teachers (e.g.1-3) plus a much larger number of sessional tutors. Only 16 schools had at least one full time academic to provide and coordinate ethics teaching and learning Only 16 schools had at least one full time academic to provide and coordinate ethics teaching and learning Consensus Statement called for this to be a senior academic - predominance of lecturers in this role Consensus Statement called for this to be a senior academic - predominance of lecturers in this role Training for teachers often provided (10) but generally optional and in-house Training for teachers often provided (10) but generally optional and in-house

Concern 1: staffing There does not seem to be a cohort of medical ethicists in waiting to take over the reins in future. Many people are interested and will help, but to create and sustain a vertical theme that works over 5 years requires considerable investment of personal time, energy and leadership. There does not seem to be a cohort of medical ethicists in waiting to take over the reins in future. Many people are interested and will help, but to create and sustain a vertical theme that works over 5 years requires considerable investment of personal time, energy and leadership. We are so stretched that taking time to review / evaluate / innovate is very difficult. We are so stretched that taking time to review / evaluate / innovate is very difficult. Lack of clinical academic staff. Lack of time / resources to support theme. Lack of clinical academic staff. Lack of time / resources to support theme. As numbers of students increase, loss of either curriculum time, or small group teaching. As numbers of students increase, loss of either curriculum time, or small group teaching. As lectures are cheaper to provide than seminars, there could be pressure to abandon seminars. As lectures are cheaper to provide than seminars, there could be pressure to abandon seminars.

Concern 1: staffing The relevance, depth and vibrancy of the programme could be lost, especially through failure to support and develop both specialist and generic clinical teachers, not least through the many competing pressures on their time and attention. The relevance, depth and vibrancy of the programme could be lost, especially through failure to support and develop both specialist and generic clinical teachers, not least through the many competing pressures on their time and attention. I think ethics needs a product champion in every medical school – it is easy for it to become everyone’s – and therefore no-one’s - responsibility. I think ethics needs a product champion in every medical school – it is easy for it to become everyone’s – and therefore no-one’s - responsibility. In 2000 or so everything looked rosy; now we're under great pressure, RAE-obsessed senior staff have put at least one post under threat, and the incentives to teach and to teach well are ever weaker. In 2000 or so everything looked rosy; now we're under great pressure, RAE-obsessed senior staff have put at least one post under threat, and the incentives to teach and to teach well are ever weaker.

Questions for today  How can we retain and develop existing well qualified and experienced staff? Staffing Staffing

Questions for today  How can we retain and develop existing well qualified and experienced staff?  How do we recruit and groom the next generation? Staffing Staffing

Questions for today  How can we retain and develop existing well qualified and experienced staff?  How do we recruit and groom the next generation?  What training is needed for ethics teachers? Staffing Staffing

Questions for today  How can we retain and develop existing well qualified and experienced staff?  How do we recruit and groom the next generation?  What training is needed for ethics teachers?  How do we resist threats to staff time, for example from increased student numbers and the pressures of clinical or research work? Staffing Staffing

Concern 2: graduating without ethics competencies The concern: a shortfall in ethics core competencies does not preclude graduation The concern: a shortfall in ethics core competencies does not preclude graduation 15 schools (68%) answered yes to the following question in the questionnaire: 15 schools (68%) answered yes to the following question in the questionnaire: “Q: Is it possible for a student to graduate if they fail their ethics assessment?”

Concern 2: graduating without ethics competencies Technically yes- but it is unlikely to occur, as there is sufficient ethics in the exam to require a very high mark in all other components to offset a fail. Technically yes- but it is unlikely to occur, as there is sufficient ethics in the exam to require a very high mark in all other components to offset a fail. Yes, but many students leave the course if they fail an assessment in year 1 or 2, and it is possible for a student not to graduate if they fail an essential part of finals - so on principle a student could fail if they do something 'unethical' in finals. Yes, but many students leave the course if they fail an assessment in year 1 or 2, and it is possible for a student not to graduate if they fail an essential part of finals - so on principle a student could fail if they do something 'unethical' in finals. Until recently this was not the case. It now is so. This is one area of our work that could improve. Until recently this was not the case. It now is so. This is one area of our work that could improve.

Questions for today  Is this a real issue? In practice, do students graduate having failed ethics competencies? Graduating without ethics competencies Graduating without ethics competencies

Questions for today  Is this a real issue? In practice, do students graduate having failed ethics competencies?  If so, do we think this is acceptable? Graduating without ethics competencies Graduating without ethics competencies

Questions for today  Is this a real issue? In practice, do students graduate having failed ethics competencies?  If so, do we think this is acceptable?  If not, how can we ensure that a lack of ethics competencies is a barrier to progression? Graduating without ethics competencies Graduating without ethics competencies

Questions for today  Is this a real issue? In practice, do students graduate having failed ethics competencies?  If so, do we think this is acceptable?  If not, how can we ensure that a lack of ethics competencies is a barrier to progression?  Is this a particular problem for schools that use integrated assessment? Graduating without ethics competencies Graduating without ethics competencies

Concern 3: greater integration The concern: need still greater integration The concern: need still greater integration Years ago we used to teach one isolated ethics session in an afternoon, which let the students to see ethics as something external to medicine, which they could chose to ignore. Years ago we used to teach one isolated ethics session in an afternoon, which let the students to see ethics as something external to medicine, which they could chose to ignore. Integration of ethics teaching has not occurred, no one person taking responsibility in planning. Integration of ethics teaching has not occurred, no one person taking responsibility in planning.

Questions for today  How can we continue the good start that has been made integrating ethics into the undergraduate curriculum? Greater integration Greater integration

Questions for today  How can we continue the good start that has been made integrating ethics into the undergraduate curriculum?  Is this a real issue or a ‘teacher’s eye’ view? Greater integration Greater integration

Concern 4: curriculum topics The concern: key topics outlined in the Consensus Statement not covered or covered sub-optimally The concern: key topics outlined in the Consensus Statement not covered or covered sub-optimally Four topics not well covered (in yellow) Four topics not well covered (in yellow)  Informed consent and refusal of treatment  Clinical relationship, truthfulness, trust and good communication  Confidentiality and good clinical practice  Medical research  Human reproduction  The ‘new genetics’  Children  Mental disorders and disability  Life, death, dying and killing  Vulnerabilities created by the duties of doctors and medical students  Resource allocation  Rights

Questions for today  Are the 12 topics in the Consensus Statement important? Curriculum topics Curriculum topics

Questions for today  Are the 12 topics in the Consensus Statement important?  Why aren’t they covered? Are they still relevant? Curriculum topics Curriculum topics

Questions for today  Are the 12 topics in the Consensus Statement important?  Why aren’t they covered? Are they still relevant?  If they are important, how can we ensure they are covered? Curriculum topics Curriculum topics

Concern 5: theoretical aspects The concern: heavily theoretical aspects of ethics are unpopular with students The concern: heavily theoretical aspects of ethics are unpopular with students Most respondents agreed that both critical and normative medical ethics needed to be present in the curriculum but difficult to make some aspects appealing to students. Most respondents agreed that both critical and normative medical ethics needed to be present in the curriculum but difficult to make some aspects appealing to students. “Q: What is the balance between critical medical ethics (e.g. ethical theory, analysis, argument) and normative medical ethics (e.g. expected behaviour in given situations, including professional and legal obligations) at your medical school?”

Concern 5: theoretical aspects Previously, there was greater emphasis on ethical theory, but students found this confusing and ‘dry’ according to their evaluations. Integrating theory into resolving dilemmas has resulted in greater student enjoyment without diluting the teaching of the theory. Previously, there was greater emphasis on ethical theory, but students found this confusing and ‘dry’ according to their evaluations. Integrating theory into resolving dilemmas has resulted in greater student enjoyment without diluting the teaching of the theory. I often use the analogy of engineering maths, a subject that can be frustrating for a pure mathematician to teach, as engineers only want to know what they need to know. In the field of medical ethics, such a balance can frustrate a pure philosopher, but I think we need to be realistic. I often use the analogy of engineering maths, a subject that can be frustrating for a pure mathematician to teach, as engineers only want to know what they need to know. In the field of medical ethics, such a balance can frustrate a pure philosopher, but I think we need to be realistic.

Concern 5: theoretical aspects Few medical students seem to have a bent for philosophical scholarship. Perhaps this is why they go into medicine! Few medical students seem to have a bent for philosophical scholarship. Perhaps this is why they go into medicine! Students disliked ethical theory as they felt it was boring. Students disliked ethical theory as they felt it was boring. We have improved things by trying to make learning practical and relevant. However, I suspect that this has been at the expense of depth of theoretical learning. Medical students seem mostly very action-oriented and rather against thoughtful but incisive reflection. We have improved things by trying to make learning practical and relevant. However, I suspect that this has been at the expense of depth of theoretical learning. Medical students seem mostly very action-oriented and rather against thoughtful but incisive reflection. Students should always be able to ask – at any stage – and receive a coherent answer to question: “What is the clinical relevance of what you (the lecturer) are saying?” Students should always be able to ask – at any stage – and receive a coherent answer to question: “What is the clinical relevance of what you (the lecturer) are saying?”

Questions for today  How much critical medical ethics is appropriate to include within undergraduate courses? Theoretical aspects Theoretical aspects

Questions for today  How much critical medical ethics is appropriate to include within undergraduate courses?  How can it be learnt by students in a way they will find interesting and relevant? Theoretical aspects Theoretical aspects

Summary Undergraduate ethics learning, teaching and assessment has come a long way in the last decade – but there is still much to be done! Undergraduate ethics learning, teaching and assessment has come a long way in the last decade – but there is still much to be done! We hope that during the course of the day, you will: We hope that during the course of the day, you will:  Refer back to the study findings  Discuss them, particularly the areas of concern  Make recommendations for future directions via the workshops

And finally, thank you once again to those individuals that spent time completing the questionnaire.