CONCEPTS, COMPONENTS, & CONFIGURATIONS ethics, education
An Ethics Curriculum for Teaching Emergency Medicine Residents Instruction in medical ethics has become standard in undergraduate medical education within the past decade; more recently, several specialty boards have formally endorsed ethics teaching and evaluation for residents as well. However, the current emergency medicine Core Content, representing emergency medicine's central body of knowledge, makes no specific mention of ethics. An ethics curriculum is proposed to remedy this gap in the emergency medicine residency curriculum. Issues frequently encountered in the emergency department are emphasized, and topics include moral foundations of clinical medicine, the unique ethical concerns of emergency medicine, patient competence, informed consent and refusal of treatment, truthfulness, confidentiality, foregoing life-sustaining treatment, duty to provide care, moral issues in disaster medicine, allocation of health care, and research and teaching involving human subjects. Educational objectives and readings for each of these topics are presented along with sample case scenarios to be used in a small group discussion format. [Moskop JC, Mitchell JM, Ray VG: An ethics curriculum for teaching emergency medicine residents. Ann Emerg Med February 1990;19:187-192.] INTRODUCTION During the past decade, ethics and human values teaching has become a standard part of undergraduate medical curriculum. In a recent survey, the Association of American Medical Colleges reported that 95 of the 126 US medical schools (75%) require at least one human values course during the first or second yearJ More recently, several specialty boards have formally endorsed ethics training and evaluation in graduate education as well. z,3 In addition, the American Board of Pediatrics has included ethical decisionmaking as a subject area in which candidates are examined for certification. 3 Because emergency physicians care for such a wide variety of patients, they are likely to encounter a full range of ethical issues in their practices. Moreover, because of the special setting in which they practice, emergency physicians may confront some unique moral problems in their own specialty. 4 Arguably, then, the inclusion of ethics teaching in the emergency medicine residency curriculum can serve a valuable purpose in enabling residents to recognize and resolve moral problems more successfully. Yet the latest revision of the emergency medicine Core Content, representing emergency medicine's central body of knowledge for training of residents, makes no specific mention of ethics; it considers related subjects only under the categories of "administrative aspects of emergency medicine" and "physician interpersonal skills. "5 To remedy this gap, we propose an ethics curriculum for emergency medicine residency training that emphasizes issues and gives examples of problems frequently encountered in the emergency department.
John C Moskop, PhD* Joyce M Mitchell, MD, FACEPt V Gall Ray, MD, FACEPt Greenville, North Carolina From the Departments of Medical Humanities* and Emergency Medicine, l East Carolina University School of Medicine, Greenville, North Carolina. Received for publication April 25, 1989. Revision received August 15, 1989. Accepted for publication September 28, 1989. Presented at the Society for Health and Human Values Residency Interest Group Session in Chicago, Illinois, November 1988. Address for reprints: Joyce M Mitchell, MD, FACER Department of Emergency Medicine, East Carolina University School of Medicine/Pitt County Memorial Hospital, PC Box 6028, Greenville, North Carolina 27835-6028.
CURRICULUM DESIGN Because of the differences in specialty practice and, therefore, the various types of ethical issues that may be encountered, emergency medicine education should provide an ongoing learning experience in medical ethics with emphasis on special situations frequently encountered in the ED. The
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TABLE. Emergency medicine Core Content and objectives
Core Topic
Educational Objectives
Section I: Introduction: Basic Moral Foundations of Clinical Medicine Ethics -- definition Foundations Relationship of ethics, law, and professional etiquette
Recognize different connotations of the term "ethics"
Section U: Applying Ethics to Emergency Medicine Distinctive features Resident's role Models of moral deliberation
Reflect on how moral issues may arise in emergency medical care
Review major sources and principles of professional ethics Reflect on the relationship of ethics, law, and professional etiquette
Discuss the resident's role in the moral decision-making process Understand the process of moral decision-making in emergency medicine
Section II1: Patient Competence Components of competence
Identify basic components of patient competence for medical decisionmaking
Assessment criteria
Discuss different criteria that have been proposed for determining when a patient is competent, specifically age, impairment, and suicidal ideation
Assessment procedures
Determine who should assess competence in different settings
Section iV: Informed Consent and Refusal of Treatment Basic elements Standards of disclosure Exceptions
Section V: Truthfulness in the Physician-Patient Relationship Truthfulness -- definition Value Withholding information
Section VI: Confidentiality Origins Threats to confidentiality Exceptions
proposed curriculum has been designed around 11 "core topics" with specific educational objectives; these are detailed in the curriculum outline {Table). Many of the topics, such as " c o m p e t e n c e , " " i n f o r m e d consent," " t r u t h f u l n e s s , " "confidentiality," "allocation of health care services," and "research on h u m a n subjects," are standard topics in medical ethics courses. 6 Other areas, such as the "duty to provide emergency care" and "moral issues in disaster medicine," have specific significance for emergency medicine. We believe that the concepts and methods of moral decision-making 128/188
Recognize the basic elements of a valid consent Know what kinds of and how much information must be provided for an informed consent Know when informed consent to treatment is not required or when the rights of others supersede the patient's rights
Recognize different connotations of the terms "telling the truth" and "lying" Understand the value of a policy of truthfulness identify situations in which physicians may withhold information or lie to patients Recognize the sources of the doctrine of medical confidentiality Identify threats to the confidentiality of patient information Recognize when confidentiality may justifiably be violated
are best taught in an informal seminar format. This encourages giveand-take as participants "try out" positions and arguments and colleagues respond. Each section is covered in a 60- to 90-minute session that can be given every two months so that the entire curriculum is covered over a two-year period. Each topic has assigned reading (Figure 1) and, except for the introductory section, case examples to direct the discussion (Figure 2). To capture the special concerns and approaches of emergency physicians, m a n y of the assigned readings are drawn from emergency medicine literature. These references Annals of Emergency Medicine
are organized according to their respective section heading and are suggested as required or supplemental. Preparatory reading is essential to successful conferences, as the scope of the i n f o r m a t i o n is too vast to cover fully in the allotted time. The number of required articles has been limited to the most pertinent to encourage compliance. The introductory section uses basic reading material to define general concepts and can be incorporated annually as an orientation session to provide a foundation for incoming residents for subsequent sections covered later in the year. In the other 19:2 February 1990
TABLE. Emergency medicine Core Content and objectives (continued) Core Topic
Educational Objectives
Section VII: Foregoing Life-Sustaining Treatment Withholding or withdrawal of care
Discuss the reasons for using or foregoing life-prolonging medical treatment
CPR in the ED
Evaluate proposed criteria for withholding and discontinuing CPR in emergency situations
Advance directives for care
Understand new mechanisms for making treatment decisions in lifethreatening circumstances
Section VIII: Duty to Provide Emergency Medical Care Duty to treat
Discuss professional responsibilities to provide emergency care
Exceptions
Describe the boundaries of the physician's duty to provide medical care
Transfer of care
Reflect on the justifiability of patient transfer for economic reasons
Section IX: Moral Issues in Disaster Medicine Disaster medicine
Discuss the scope and limits of medical effectiveness in disaster situations
Triage
Identify the moral principles underlying medical triage systems
Section X: Allocation of Health Care Services Cost analysis Cost containment Access to health care Assurance of quality care
Recognize major reasons for the rising cost of health care Identify and evaluate different measures designed to control health care costs Understand the impact of cost containment measures on health care for indigent patients Understand issues for the emergency physician in providing quality care
Section Xh Research and Teaching Involving Human Subjects Codes and principles Institutional review Special problems Teaching cases
sections, the first ten to 15 minutes are spent reviewing the readings and developing basic concepts. This is followed by an open discussion of the readings and case examples by residents and faculty members. The case examples have been developed to give specificity to the individual objectives within each core topic. Participants often want to address specific problems they have encountered during their medical practice. The format of these sessions can accomm o d a t e a d d i t i o n a l e x a m p l e s or points of interest, as long as the proposed objectives are met. Our curriculum is currently in its second year of implementation in the emergency medicine residency program at East Carolina U n i v e r s i t y 19:2 February 1990
Review moral principles proposed for research on human subjects Understand current mechanisms for protecting human research subjects Recognize special problems facing research in emergency situations Examine the boundaries surrounding quality patient care in relation to resident education
School of Medicine. A l t h o u g h we have not objectively evaluated the effectiveness of the curriculum, we have found the discussions to be lively and informative. For completeness, we intend to develop an instrument to evaluate resident attitudes, knowledge, and modification in ethical decision-making through use of this structured learning program. DISCUSSION Ethical decision-making should not be viewed as a purely intuitive process. The variety and complexity of the ethical decisions an emergency physician must make are well illustrated by the case examples developed. Basic concepts and analytic skills learned early in medical educaAnnals of Emergency Medicine
tion can be reinforced by giving them clinical relevance w h i l e p r a c t i c e habits are still in formation. Practical ethical training can provide a strong foundation for use throughout the individual's career. Realizing the practical aspects of applying these principles to everyday situations can bring real meaning to theoretical concepts. In this way, the emergency physician can learn to make considered, rational ethical choices when faced with decisions in daily practice. In addition to decision-making strategies, this practical emphasis m a y also strengthen the new physician's appreciation for the importance of folFIGURE 1. Recommended reading. 189/129
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Section h Introduction: Basic Moral Foundations of Clinical Medicine Required American Medical Association: Principles of medical ethics (1980), in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 122. Clouser KD: Medical ethics: Some uses, abuses and limitations. N Engl J Mud 1975;293:384-387. Hippocratic oath, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 121. Supplemental Beauchamp TL, Childress JF (eds): Principles of Biomedical Ethics. New York, Oxford University Press, 1984. Pellegrino ED: Toward a reconstruction of medical morality: The primacy of the act of profession and the fact of illness. J Mud Philos 1979;4:32-56. Section Ih Applying Ethics to Emergency Medicine Required Sanders AB: Unique aspects of ethics in emergency medicine, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 9-12. Winkenwerder W: Ethical dilemmas for house staff physicians. JAMA 1985;254:3454-3457. Supplemental Iserson KV: An approach to ethical problems in emergency medicine, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 35-41. Jonson AR, Siegler M, Winslade WJ (eds): Clinical Ethics. New York, MacMillan, 1986. Lammers SE, Childs AW: A cardiac arrest and a second hand report. Hastings Cent Rep December 1986;16: 15-17. Section IIh Patient Competence Required Brock D: Informed participation in decisions, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 47-52. Clarke JR, Sorenson JH, Hare JE: The limits of paternalism in emergency care. Hastings Cent Rep 1980;10:20-22. Tierney WM, Weinberger M, Greene JY, etal: Jehovah's witnesses and blood transfusion: Physicians' attitudes and legal precedents. South Mud J 1984;77:473-478. Supplemental Decisionmaking capacity and voluntariness, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 55-68. Who is incapacitated and how is it to be determined, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 169-175. Section IV: Informed Consent and Refusal of Treatment Required Boisaubin EV, Dresser R: Informed consent in emergency care: Illusion and reform. Ann Emerg Mud 1987;16:62-67. Borak J, Veilleux S: Informed consent in emergency settings. Ann Emerg Mud 1984;13:731-735.
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Ladd RE: Patients without choices: The ethics of decisionmaking in e m e r g e n c y medicine. J Emerg Mud 1985;3: 149-156.
Supplemental Fairey WF: Ordering a blood alcohol level in the emergency room: A medical-legal dilemma. J SC Mud Assoc 1986;82:536-537. Holroyd B, Shalit M, Kallsen G, etal: Prehospital patients refusing care. Ann Emerg IVied 1988;17:957-963. NC Gun Stats, § 90-21.13, Informed Consent to Health Care Treatment or Procedure. NC Gun Stats, §§ 90-21.1 through 90-21.5, Treatment of Minors. Tait K, Winslow G: Beyond consent -- The ethics of decisionmaking in emergency medicine. West J Mud 1977;126: 156-159. The communication process, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 63-73. Section V: Truthfulness in the Physician-Patient Relationship Required Anonymous: The lie. JAMA 1981;245:173. Cabot R: The use of truth and falsehood in medicine: An experimental study. Am Mud 1903;5:344-349. Reprinted in Reiser SJ, Dyck A J, Curran WJ (eds): Ethics in Medicine. Cambridge, Massachusetts, MIT Press, 1977, p 213-220. Supplemental Beauchamp TL: Uncertain diagnosis and the uncooperative patient, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 65-68. Lindell AR: Inappropriate silence. J PreY Nurs 1986;2:339. Section Vh Confidentiality Required AIDS poses dilemma for doctor-patient confidentiality. AIDS Alert 1988;3:133-138. Smith HM: Legal requirements for notification, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 92-97. Supplemental Abrams N, Buckner MD, Levin RI: The urban emergency department: The issue of professional responsibility. Ann Emerg Mud 1982;11:86-90. Faden R: Answering questions from "relatives" on the phone or in person, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 97-99. Pointer JE, Small JB: Emergency physicians' duty to warn and protect: A critique and guidelines. J Emerg Mud 1986;4: 75-78. Siegler M: Confidentiality in medicine -- A decrepit concept. N Engl J Mud 1982;307:1518-1521. Thorburn KM: When x-rays show, must prison doctors tell? Hastings Cent Rep June 1985;15:17-18. Section VII: Foregoing Life-Sustaining Treatment Required American College of Emergency Physicians: Medical, moral, legal and ethical aspects of resuscitation for the patient who will have minimal ability to function or ultimately survive. Ann Emerg Mud 1985;14:919-926.
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Eisendrath SJ, Jonsen AR: The living will: Help or hindrance? JAMA 1983;249:2054-2058.
Supplemental American College of Emergency Physicians: Guidelines for "do not resuscitate" orders in the prehospital setting. Ann Emerg Mad 1988;17:1106-1108. Baskett PJF, Sowden G, Robins D: Ethics in cardiopulmonary resuscitation. Am J Emerg Med 1984;2:273-274. Brody BA: Resuscitating a patient with no vital signs, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 109-114. Cassel CK: Ethical issues in the emergency care of elderly persons: A framework for decisionmaking. Mt Sinai J Med 1987;54:9-13. Chipman C, Adelman R, Sexton G: Criteria for cessation of CPR in the emergency department. Ann Emerg Mad 1981;10:11-17. Tomlinson T, Brody H: Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988;318:43-46. Eisenberg MS, Cummins RO: Termination of CPR in the prehospital arena (editorial). Ann Emerg Med 1985;14: 1106-1107. Hadorn DC, Lavoie FW, Barber RL: Scientific and ethical considerations in "no code" orders (letter). Ann Emerg Med 1988;17:1260-1261. Lavoie FW, Dolan MC, Danzl DF, et al: Recurrent resuscitation and "no code" orders in a 27-year-old spray paint abuser. Ann Emerg Mad 1987;16:1266-1273. McConnell T: When not to resuscitate, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 115-119. Rachels J: Active and passive euthanasia. N Engl J Med 1975;292:78-80. Smith JP, Bodai BI: Guidelines for discontinuing prehospital CPR in the emergency department -- A review. Ann Emerg Med 1985;14:t093-1098. Standards for CPR and ECC, part VIII: Medicolegal considerations and recommendations. JAMA 1 9 8 6 ; 2 5 5 : 2979-2984.
Section Vllh Duty to Provide Emergency Medical Care Required American College of Emergency Physicians: AIDS -- Statement of principles and interim recommendations for emergency department personnel and prehospital care providers. Ann Emerg Med 1988;17:1249-1251. American College of Emergency Physicians: Guidelines concerning work stoppages and slowdowns. Ann Emerg Med 1985;14:77. American College of Emergency Physicians: Guidelines for transfer of patients. Ann Emerg Mad 1985;14:1221-1222. Annas G J: Your money or your life: "Dumping" uninsured patients from hospital emergency wards. Am J Pubfic Health 1986; 76: 74-77. Fass P: Patient transfer for economics. Ann Emerg Mad 1986;15:970-971. Henry MC, Margulies JL, Olson CM: Economic triage: Emergency physicians should say "no" (letter). Ann Emerg Med 1986;15:983-984. Wrenn K: No insurance, no admission. N Engl J Med 1985;312:373-374.
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Supplemental Annas G J: Adam Smith in the emergency room. Hastings Cent Rap August 1985;15:16-18. Ansell DA, Schifl RL: Patient dumping: Status, implications and policy recommendations. JAMA 1987;257:1500-1502. Curran WJ: Economic and legal considerations in emergency care. N Engl J Med 1985;312:374-375. Reich WT: A movable medical crisis, in Meskop JC, Kopelman L (eds): Ethics and Critical Care Medicine. Dordrecht, D Reidel, 1985, p 1-10. Relman AS: Economic considerations in emergency care: What are hospitals for? N Engl J Med 1985;312:372-373. Sanders AB: Resuscitation of an AIDS victim, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 150-154. Zuger A, Miles SH: Physicians, AIDS, and occupational risk. JAMA 1987;258:1924-1928. Zuger A: Professional responsibilities in the AIDS generation. Hastings Cent Rep June 1987;17:16-20.
Section IX: Moral Issues in Disaster Medicine Required Bell NK: Triage in medical practices: An unacceptable model? Soc Sci Med 1981;15F:151-156. Pledger HG: Triage of casualties after nuclear attack. Lancet 1986:678-679.
Supplemental Leaning J: Burn and blast casualties: Triage in nuclear war, in Solomon F, Marston RQ (eds): The Medical Impfications of Nuclear War. Washington, DC, National Academy Press, 1986, p 254-289. Winslow GR: Principles for triage, in Triage and Justice, Berkeley, University of California Press, 1982, p 60-109.
Section X: Allocation of Health Care Services Required Schwartz WB: The inevitable failure of current cost-containment strategies. JAMA 1987;257:220-224. Thurow LC: Medicine versus economics. N Engl J Med 1985;313:611-614.
Supplemental Evans RW: Health care technology and the inevitability of res o u r c e a l l o c a t i o n and rationing decisions. JAMA 1983;249:part 1, 2047-2053;Part 2, 2208-2219. Frader J: Referral back to a poor primary health care provider, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 215-217. Hilfiker D: Unconscious on a corner ... JAMA 1987;258: 3155-3156. Morreim EH: Cost containment: Challenging fidelity and justice. Hastings Cent Rep December 1988;18:20-25. Rachels J: Responsibilities for monitoring and maintaining quality of care -- Mistakes, in iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 196-200.
Section Xh Research and Teaching Involving Human Subjects Required Abramson NS, Meisel A, Safar P: Deferred consent: A new approach for resuscitation research on comatose patients. JAMA 1986;255:2466-2471.
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Nuremberg Code, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 510. Summary of DHHS rules and procedures governing research with human subjects, in President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Protecting Human Subjects. Washington, DC, Government Printing Office, 1981, p 110-117. World Medical Association: Declaration of Helsinki, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 511-512.
Supplemental Amey BD: The ethics of emergency medicine research. Ann Emerg Med 1982;11:518.
F I G U R E 2. C a s e e x a m p l e s . l o w i n g an e t h i c a l c o u r s e of a c t i o n .
SUMMARY We have presented a structured but flexible c u r r i c u l u m that m a y be used i n p a r t or i n i t s e n t i r e t y b y o t h e r e m e r g e n c y m e d i c i n e r e s i d e n c y prog r a m s . In a d d i t i o n , w e p r o p o s e t h a t t h e s u b j e c t of e t h i c s be i n c o r p o r a t e d as a m a j o r c a t e g o r y i n t h e e m e r g e n c y medicine Core Content with attention to the core topics presented here. This will ensure that proper e m p h a s i s and d e v o t i o n to t e a c h i n g are a c c o r d e d t o t h e s e e s s e n t i a l c o m p o n e n t s of e m e r g e n c y p h y s i c i a n education.
REFERENCES 1. Bickel J: Human values teaching programs in the clinical education of medical students. J Med Educ t987;62:369-378. 2. American Board of Internal Medicine, Subcommittee on Evaluation of Humanistic Qualities in the Internist: Evaluation of humanistic qualities in the internist. Ann Intern Med 1983; 99: 720-724. 3. American Board of Pediatrics, Medical Ethics Subcommittee: Teaching and evaluation of interpersonal skills and ethical decision making i n pediatrics. Pediatrics 1987;79:829-833. 4. Sanders AB: Unique aspects of ethics in emergency medicine, in Iserson KV, Sanders AB, Mathieu DR, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1985,
Brody BA: Practicing cardiopulmonary resuscitation (CPR) procedures, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 74. Fost NC: Human subjects in cardiopulmonary resuscitation research, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 77-81. Iserson KV: Using a cadaver to practice and teach. Hastings Cent Rep June 1986;16:28-29. Jellinek M, Lazare A: Relationships between academic departments of psychiatry and pharmaceutical companies. Am J Psychiatry 1979;136:827-829. Powers RD: Multiple authorship, basic research, and other trends in the emergency medicine literature (1975 to 1986). Am J Emerg Med 1988;6:647-650. Sanders AB: Human subjects research in emergency medicine (letter). Ann Emerg Med 1984;13:1170-1171.
Section Ih Applying Ethics to Emergency Medicine Resident's Role A patient arrives in full code arrest after her family physician has called and told you of her medical history. She has widely metastatic breast cancer and is in the midst of chemotherapy. Her physician believes full resuscitative efforts are warranted. There is no family. The attending emergency physician complies with this guideline and directs the senior resident in emergency medicine to intubate and further resuscitate the patient. The resident, having read the medical record and noting the advanced cachectic state of the patient, voices concerns over these types of efforts.
Section V: Truthfulness in the Physician-Patient Relationship Withholding Information An elderly woman has injured her shoulder in a motor vehicle accident. She is very tearful. In evaluating the patient, a radiograph of the shoulder is negative except for a possible mass in the lung. You send her back for a chest radiograph, which confirms a pulmonary nodule and hilar mass, most likely a malignant process. You contact her family physician of many years, and he tells you the patient has recently been depressed because of disability due to medical problems including crippling arthritis and eye surgery with complications and visual impairment. Her physician feels strongly that any "bad news" should come from him and that he will see her in the morning and begin evaluation of the lung mass. The patient asks what the chest radiograph showed. For a complete compilation of the case examples, please contact Joyce M Mitchell, MD, FACER
p 9-12. 5. American College of Emergency Physicians, Special Committee on the Core Content Revision: Emergency medicine Core Content. Ann
Emerg Med 1986;15:853-862.
6. Culver CM, Clouser KD, Gert B, et al: Basic curricular goals in medical ethics. N Engl J Med 1985;312:253-256.
See r e l a t e d editorial, p 210
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An Ethics Curriculum for Teaching Emergency Medicine Residents Instruction in medical ethics has become standard in undergraduate medical education within the past decade; more recently, several specialty boards have formally endorsed ethics teaching and evaluation for residents as well. However, the current emergency medicine Core Content, representing emergency medicine's central body of knowledge, makes no specific mention of ethics. An ethics curriculum is proposed to remedy this gap in the emergency medicine residency curriculum. Issues frequently encountered in the emergency department are emphasized, and topics include moral foundations of clinical medicine, the unique ethical concerns of emergency medicine, patient competence, informed consent and refusal of treatment, truthfulness, confidentiality, foregoing life-sustaining treatment, duty to provide care, moral issues in disaster medicine, allocation of health care, and research and teaching involving human subjects. Educational objectives and readings for each of these topics are presented along with sample case scenarios to be used in a small group discussion format. [Moskop JC, Mitchell JM, Ray VG: An ethics curriculum for teaching emergency medicine residents. Ann Emerg Med February 1990;19:187-192.] INTRODUCTION During the past decade, ethics and human values teaching has become a standard part of undergraduate medical curriculum. In a recent survey, the Association of American Medical Colleges reported that 95 of the 126 US medical schools (75%) require at least one human values course during the first or second yearJ More recently, several specialty boards have formally endorsed ethics training and evaluation in graduate education as well. z,3 In addition, the American Board of Pediatrics has included ethical decisionmaking as a subject area in which candidates are examined for certification. 3 Because emergency physicians care for such a wide variety of patients, they are likely to encounter a full range of ethical issues in their practices. Moreover, because of the special setting in which they practice, emergency physicians may confront some unique moral problems in their own specialty. 4 Arguably, then, the inclusion of ethics teaching in the emergency medicine residency curriculum can serve a valuable purpose in enabling residents to recognize and resolve moral problems more successfully. Yet the latest revision of the emergency medicine Core Content, representing emergency medicine's central body of knowledge for training of residents, makes no specific mention of ethics; it considers related subjects only under the categories of "administrative aspects of emergency medicine" and "physician interpersonal skills. "5 To remedy this gap, we propose an ethics curriculum for emergency medicine residency training that emphasizes issues and gives examples of problems frequently encountered in the emergency department.
John C Moskop, PhD* Joyce M Mitchell, MD, FACEPt V Gall Ray, MD, FACEPt Greenville, North Carolina From the Departments of Medical Humanities* and Emergency Medicine, l East Carolina University School of Medicine, Greenville, North Carolina. Received for publication April 25, 1989. Revision received August 15, 1989. Accepted for publication September 28, 1989. Presented at the Society for Health and Human Values Residency Interest Group Session in Chicago, Illinois, November 1988. Address for reprints: Joyce M Mitchell, MD, FACER Department of Emergency Medicine, East Carolina University School of Medicine/Pitt County Memorial Hospital, PC Box 6028, Greenville, North Carolina 27835-6028.
CURRICULUM DESIGN Because of the differences in specialty practice and, therefore, the various types of ethical issues that may be encountered, emergency medicine education should provide an ongoing learning experience in medical ethics with emphasis on special situations frequently encountered in the ED. The
19:2 February 1990
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ETHICS CURRICULUM Moskop, Mitchell & Ray
TABLE. Emergency medicine Core Content and objectives
Core Topic
Educational Objectives
Section I: Introduction: Basic Moral Foundations of Clinical Medicine Ethics -- definition Foundations Relationship of ethics, law, and professional etiquette
Recognize different connotations of the term "ethics"
Section U: Applying Ethics to Emergency Medicine Distinctive features Resident's role Models of moral deliberation
Reflect on how moral issues may arise in emergency medical care
Review major sources and principles of professional ethics Reflect on the relationship of ethics, law, and professional etiquette
Discuss the resident's role in the moral decision-making process Understand the process of moral decision-making in emergency medicine
Section II1: Patient Competence Components of competence
Identify basic components of patient competence for medical decisionmaking
Assessment criteria
Discuss different criteria that have been proposed for determining when a patient is competent, specifically age, impairment, and suicidal ideation
Assessment procedures
Determine who should assess competence in different settings
Section iV: Informed Consent and Refusal of Treatment Basic elements Standards of disclosure Exceptions
Section V: Truthfulness in the Physician-Patient Relationship Truthfulness -- definition Value Withholding information
Section VI: Confidentiality Origins Threats to confidentiality Exceptions
proposed curriculum has been designed around 11 "core topics" with specific educational objectives; these are detailed in the curriculum outline {Table). Many of the topics, such as " c o m p e t e n c e , " " i n f o r m e d consent," " t r u t h f u l n e s s , " "confidentiality," "allocation of health care services," and "research on h u m a n subjects," are standard topics in medical ethics courses. 6 Other areas, such as the "duty to provide emergency care" and "moral issues in disaster medicine," have specific significance for emergency medicine. We believe that the concepts and methods of moral decision-making 128/188
Recognize the basic elements of a valid consent Know what kinds of and how much information must be provided for an informed consent Know when informed consent to treatment is not required or when the rights of others supersede the patient's rights
Recognize different connotations of the terms "telling the truth" and "lying" Understand the value of a policy of truthfulness identify situations in which physicians may withhold information or lie to patients Recognize the sources of the doctrine of medical confidentiality Identify threats to the confidentiality of patient information Recognize when confidentiality may justifiably be violated
are best taught in an informal seminar format. This encourages giveand-take as participants "try out" positions and arguments and colleagues respond. Each section is covered in a 60- to 90-minute session that can be given every two months so that the entire curriculum is covered over a two-year period. Each topic has assigned reading (Figure 1) and, except for the introductory section, case examples to direct the discussion (Figure 2). To capture the special concerns and approaches of emergency physicians, m a n y of the assigned readings are drawn from emergency medicine literature. These references Annals of Emergency Medicine
are organized according to their respective section heading and are suggested as required or supplemental. Preparatory reading is essential to successful conferences, as the scope of the i n f o r m a t i o n is too vast to cover fully in the allotted time. The number of required articles has been limited to the most pertinent to encourage compliance. The introductory section uses basic reading material to define general concepts and can be incorporated annually as an orientation session to provide a foundation for incoming residents for subsequent sections covered later in the year. In the other 19:2 February 1990
TABLE. Emergency medicine Core Content and objectives (continued) Core Topic
Educational Objectives
Section VII: Foregoing Life-Sustaining Treatment Withholding or withdrawal of care
Discuss the reasons for using or foregoing life-prolonging medical treatment
CPR in the ED
Evaluate proposed criteria for withholding and discontinuing CPR in emergency situations
Advance directives for care
Understand new mechanisms for making treatment decisions in lifethreatening circumstances
Section VIII: Duty to Provide Emergency Medical Care Duty to treat
Discuss professional responsibilities to provide emergency care
Exceptions
Describe the boundaries of the physician's duty to provide medical care
Transfer of care
Reflect on the justifiability of patient transfer for economic reasons
Section IX: Moral Issues in Disaster Medicine Disaster medicine
Discuss the scope and limits of medical effectiveness in disaster situations
Triage
Identify the moral principles underlying medical triage systems
Section X: Allocation of Health Care Services Cost analysis Cost containment Access to health care Assurance of quality care
Recognize major reasons for the rising cost of health care Identify and evaluate different measures designed to control health care costs Understand the impact of cost containment measures on health care for indigent patients Understand issues for the emergency physician in providing quality care
Section Xh Research and Teaching Involving Human Subjects Codes and principles Institutional review Special problems Teaching cases
sections, the first ten to 15 minutes are spent reviewing the readings and developing basic concepts. This is followed by an open discussion of the readings and case examples by residents and faculty members. The case examples have been developed to give specificity to the individual objectives within each core topic. Participants often want to address specific problems they have encountered during their medical practice. The format of these sessions can accomm o d a t e a d d i t i o n a l e x a m p l e s or points of interest, as long as the proposed objectives are met. Our curriculum is currently in its second year of implementation in the emergency medicine residency program at East Carolina U n i v e r s i t y 19:2 February 1990
Review moral principles proposed for research on human subjects Understand current mechanisms for protecting human research subjects Recognize special problems facing research in emergency situations Examine the boundaries surrounding quality patient care in relation to resident education
School of Medicine. A l t h o u g h we have not objectively evaluated the effectiveness of the curriculum, we have found the discussions to be lively and informative. For completeness, we intend to develop an instrument to evaluate resident attitudes, knowledge, and modification in ethical decision-making through use of this structured learning program. DISCUSSION Ethical decision-making should not be viewed as a purely intuitive process. The variety and complexity of the ethical decisions an emergency physician must make are well illustrated by the case examples developed. Basic concepts and analytic skills learned early in medical educaAnnals of Emergency Medicine
tion can be reinforced by giving them clinical relevance w h i l e p r a c t i c e habits are still in formation. Practical ethical training can provide a strong foundation for use throughout the individual's career. Realizing the practical aspects of applying these principles to everyday situations can bring real meaning to theoretical concepts. In this way, the emergency physician can learn to make considered, rational ethical choices when faced with decisions in daily practice. In addition to decision-making strategies, this practical emphasis m a y also strengthen the new physician's appreciation for the importance of folFIGURE 1. Recommended reading. 189/129
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Section h Introduction: Basic Moral Foundations of Clinical Medicine Required American Medical Association: Principles of medical ethics (1980), in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 122. Clouser KD: Medical ethics: Some uses, abuses and limitations. N Engl J Mud 1975;293:384-387. Hippocratic oath, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 121. Supplemental Beauchamp TL, Childress JF (eds): Principles of Biomedical Ethics. New York, Oxford University Press, 1984. Pellegrino ED: Toward a reconstruction of medical morality: The primacy of the act of profession and the fact of illness. J Mud Philos 1979;4:32-56. Section Ih Applying Ethics to Emergency Medicine Required Sanders AB: Unique aspects of ethics in emergency medicine, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 9-12. Winkenwerder W: Ethical dilemmas for house staff physicians. JAMA 1985;254:3454-3457. Supplemental Iserson KV: An approach to ethical problems in emergency medicine, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 35-41. Jonson AR, Siegler M, Winslade WJ (eds): Clinical Ethics. New York, MacMillan, 1986. Lammers SE, Childs AW: A cardiac arrest and a second hand report. Hastings Cent Rep December 1986;16: 15-17. Section IIh Patient Competence Required Brock D: Informed participation in decisions, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 47-52. Clarke JR, Sorenson JH, Hare JE: The limits of paternalism in emergency care. Hastings Cent Rep 1980;10:20-22. Tierney WM, Weinberger M, Greene JY, etal: Jehovah's witnesses and blood transfusion: Physicians' attitudes and legal precedents. South Mud J 1984;77:473-478. Supplemental Decisionmaking capacity and voluntariness, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 55-68. Who is incapacitated and how is it to be determined, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 169-175. Section IV: Informed Consent and Refusal of Treatment Required Boisaubin EV, Dresser R: Informed consent in emergency care: Illusion and reform. Ann Emerg Mud 1987;16:62-67. Borak J, Veilleux S: Informed consent in emergency settings. Ann Emerg Mud 1984;13:731-735.
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Ladd RE: Patients without choices: The ethics of decisionmaking in e m e r g e n c y medicine. J Emerg Mud 1985;3: 149-156.
Supplemental Fairey WF: Ordering a blood alcohol level in the emergency room: A medical-legal dilemma. J SC Mud Assoc 1986;82:536-537. Holroyd B, Shalit M, Kallsen G, etal: Prehospital patients refusing care. Ann Emerg IVied 1988;17:957-963. NC Gun Stats, § 90-21.13, Informed Consent to Health Care Treatment or Procedure. NC Gun Stats, §§ 90-21.1 through 90-21.5, Treatment of Minors. Tait K, Winslow G: Beyond consent -- The ethics of decisionmaking in emergency medicine. West J Mud 1977;126: 156-159. The communication process, in President's Commission for the Study of Ethical Problems in Medicine: Making Health Care Decisions. Washington, DC, Government Printing Office, 1982, p 63-73. Section V: Truthfulness in the Physician-Patient Relationship Required Anonymous: The lie. JAMA 1981;245:173. Cabot R: The use of truth and falsehood in medicine: An experimental study. Am Mud 1903;5:344-349. Reprinted in Reiser SJ, Dyck A J, Curran WJ (eds): Ethics in Medicine. Cambridge, Massachusetts, MIT Press, 1977, p 213-220. Supplemental Beauchamp TL: Uncertain diagnosis and the uncooperative patient, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 65-68. Lindell AR: Inappropriate silence. J PreY Nurs 1986;2:339. Section Vh Confidentiality Required AIDS poses dilemma for doctor-patient confidentiality. AIDS Alert 1988;3:133-138. Smith HM: Legal requirements for notification, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 92-97. Supplemental Abrams N, Buckner MD, Levin RI: The urban emergency department: The issue of professional responsibility. Ann Emerg Mud 1982;11:86-90. Faden R: Answering questions from "relatives" on the phone or in person, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 97-99. Pointer JE, Small JB: Emergency physicians' duty to warn and protect: A critique and guidelines. J Emerg Mud 1986;4: 75-78. Siegler M: Confidentiality in medicine -- A decrepit concept. N Engl J Mud 1982;307:1518-1521. Thorburn KM: When x-rays show, must prison doctors tell? Hastings Cent Rep June 1985;15:17-18. Section VII: Foregoing Life-Sustaining Treatment Required American College of Emergency Physicians: Medical, moral, legal and ethical aspects of resuscitation for the patient who will have minimal ability to function or ultimately survive. Ann Emerg Mud 1985;14:919-926.
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Eisendrath SJ, Jonsen AR: The living will: Help or hindrance? JAMA 1983;249:2054-2058.
Supplemental American College of Emergency Physicians: Guidelines for "do not resuscitate" orders in the prehospital setting. Ann Emerg Mad 1988;17:1106-1108. Baskett PJF, Sowden G, Robins D: Ethics in cardiopulmonary resuscitation. Am J Emerg Med 1984;2:273-274. Brody BA: Resuscitating a patient with no vital signs, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 109-114. Cassel CK: Ethical issues in the emergency care of elderly persons: A framework for decisionmaking. Mt Sinai J Med 1987;54:9-13. Chipman C, Adelman R, Sexton G: Criteria for cessation of CPR in the emergency department. Ann Emerg Mad 1981;10:11-17. Tomlinson T, Brody H: Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988;318:43-46. Eisenberg MS, Cummins RO: Termination of CPR in the prehospital arena (editorial). Ann Emerg Med 1985;14: 1106-1107. Hadorn DC, Lavoie FW, Barber RL: Scientific and ethical considerations in "no code" orders (letter). Ann Emerg Med 1988;17:1260-1261. Lavoie FW, Dolan MC, Danzl DF, et al: Recurrent resuscitation and "no code" orders in a 27-year-old spray paint abuser. Ann Emerg Mad 1987;16:1266-1273. McConnell T: When not to resuscitate, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 115-119. Rachels J: Active and passive euthanasia. N Engl J Med 1975;292:78-80. Smith JP, Bodai BI: Guidelines for discontinuing prehospital CPR in the emergency department -- A review. Ann Emerg Med 1985;14:t093-1098. Standards for CPR and ECC, part VIII: Medicolegal considerations and recommendations. JAMA 1 9 8 6 ; 2 5 5 : 2979-2984.
Section Vllh Duty to Provide Emergency Medical Care Required American College of Emergency Physicians: AIDS -- Statement of principles and interim recommendations for emergency department personnel and prehospital care providers. Ann Emerg Med 1988;17:1249-1251. American College of Emergency Physicians: Guidelines concerning work stoppages and slowdowns. Ann Emerg Med 1985;14:77. American College of Emergency Physicians: Guidelines for transfer of patients. Ann Emerg Mad 1985;14:1221-1222. Annas G J: Your money or your life: "Dumping" uninsured patients from hospital emergency wards. Am J Pubfic Health 1986; 76: 74-77. Fass P: Patient transfer for economics. Ann Emerg Mad 1986;15:970-971. Henry MC, Margulies JL, Olson CM: Economic triage: Emergency physicians should say "no" (letter). Ann Emerg Med 1986;15:983-984. Wrenn K: No insurance, no admission. N Engl J Med 1985;312:373-374.
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Supplemental Annas G J: Adam Smith in the emergency room. Hastings Cent Rap August 1985;15:16-18. Ansell DA, Schifl RL: Patient dumping: Status, implications and policy recommendations. JAMA 1987;257:1500-1502. Curran WJ: Economic and legal considerations in emergency care. N Engl J Med 1985;312:374-375. Reich WT: A movable medical crisis, in Meskop JC, Kopelman L (eds): Ethics and Critical Care Medicine. Dordrecht, D Reidel, 1985, p 1-10. Relman AS: Economic considerations in emergency care: What are hospitals for? N Engl J Med 1985;312:372-373. Sanders AB: Resuscitation of an AIDS victim, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 150-154. Zuger A, Miles SH: Physicians, AIDS, and occupational risk. JAMA 1987;258:1924-1928. Zuger A: Professional responsibilities in the AIDS generation. Hastings Cent Rep June 1987;17:16-20.
Section IX: Moral Issues in Disaster Medicine Required Bell NK: Triage in medical practices: An unacceptable model? Soc Sci Med 1981;15F:151-156. Pledger HG: Triage of casualties after nuclear attack. Lancet 1986:678-679.
Supplemental Leaning J: Burn and blast casualties: Triage in nuclear war, in Solomon F, Marston RQ (eds): The Medical Impfications of Nuclear War. Washington, DC, National Academy Press, 1986, p 254-289. Winslow GR: Principles for triage, in Triage and Justice, Berkeley, University of California Press, 1982, p 60-109.
Section X: Allocation of Health Care Services Required Schwartz WB: The inevitable failure of current cost-containment strategies. JAMA 1987;257:220-224. Thurow LC: Medicine versus economics. N Engl J Med 1985;313:611-614.
Supplemental Evans RW: Health care technology and the inevitability of res o u r c e a l l o c a t i o n and rationing decisions. JAMA 1983;249:part 1, 2047-2053;Part 2, 2208-2219. Frader J: Referral back to a poor primary health care provider, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 215-217. Hilfiker D: Unconscious on a corner ... JAMA 1987;258: 3155-3156. Morreim EH: Cost containment: Challenging fidelity and justice. Hastings Cent Rep December 1988;18:20-25. Rachels J: Responsibilities for monitoring and maintaining quality of care -- Mistakes, in iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 196-200.
Section Xh Research and Teaching Involving Human Subjects Required Abramson NS, Meisel A, Safar P: Deferred consent: A new approach for resuscitation research on comatose patients. JAMA 1986;255:2466-2471.
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Nuremberg Code, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 510. Summary of DHHS rules and procedures governing research with human subjects, in President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Protecting Human Subjects. Washington, DC, Government Printing Office, 1981, p 110-117. World Medical Association: Declaration of Helsinki, in Beauchamp TL, Waiters LW (eds): Contemporary Issues in Bioethics. Belmont, California, Wadsworth Publishing, 1982, p 511-512.
Supplemental Amey BD: The ethics of emergency medicine research. Ann Emerg Med 1982;11:518.
F I G U R E 2. C a s e e x a m p l e s . l o w i n g an e t h i c a l c o u r s e of a c t i o n .
SUMMARY We have presented a structured but flexible c u r r i c u l u m that m a y be used i n p a r t or i n i t s e n t i r e t y b y o t h e r e m e r g e n c y m e d i c i n e r e s i d e n c y prog r a m s . In a d d i t i o n , w e p r o p o s e t h a t t h e s u b j e c t of e t h i c s be i n c o r p o r a t e d as a m a j o r c a t e g o r y i n t h e e m e r g e n c y medicine Core Content with attention to the core topics presented here. This will ensure that proper e m p h a s i s and d e v o t i o n to t e a c h i n g are a c c o r d e d t o t h e s e e s s e n t i a l c o m p o n e n t s of e m e r g e n c y p h y s i c i a n education.
REFERENCES 1. Bickel J: Human values teaching programs in the clinical education of medical students. J Med Educ t987;62:369-378. 2. American Board of Internal Medicine, Subcommittee on Evaluation of Humanistic Qualities in the Internist: Evaluation of humanistic qualities in the internist. Ann Intern Med 1983; 99: 720-724. 3. American Board of Pediatrics, Medical Ethics Subcommittee: Teaching and evaluation of interpersonal skills and ethical decision making i n pediatrics. Pediatrics 1987;79:829-833. 4. Sanders AB: Unique aspects of ethics in emergency medicine, in Iserson KV, Sanders AB, Mathieu DR, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1985,
Brody BA: Practicing cardiopulmonary resuscitation (CPR) procedures, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 74. Fost NC: Human subjects in cardiopulmonary resuscitation research, in Iserson KV, et al (eds): Ethics in Emergency Medicine. Baltimore, Williams & Wilkins, 1986, p 77-81. Iserson KV: Using a cadaver to practice and teach. Hastings Cent Rep June 1986;16:28-29. Jellinek M, Lazare A: Relationships between academic departments of psychiatry and pharmaceutical companies. Am J Psychiatry 1979;136:827-829. Powers RD: Multiple authorship, basic research, and other trends in the emergency medicine literature (1975 to 1986). Am J Emerg Med 1988;6:647-650. Sanders AB: Human subjects research in emergency medicine (letter). Ann Emerg Med 1984;13:1170-1171.
Section Ih Applying Ethics to Emergency Medicine Resident's Role A patient arrives in full code arrest after her family physician has called and told you of her medical history. She has widely metastatic breast cancer and is in the midst of chemotherapy. Her physician believes full resuscitative efforts are warranted. There is no family. The attending emergency physician complies with this guideline and directs the senior resident in emergency medicine to intubate and further resuscitate the patient. The resident, having read the medical record and noting the advanced cachectic state of the patient, voices concerns over these types of efforts.
Section V: Truthfulness in the Physician-Patient Relationship Withholding Information An elderly woman has injured her shoulder in a motor vehicle accident. She is very tearful. In evaluating the patient, a radiograph of the shoulder is negative except for a possible mass in the lung. You send her back for a chest radiograph, which confirms a pulmonary nodule and hilar mass, most likely a malignant process. You contact her family physician of many years, and he tells you the patient has recently been depressed because of disability due to medical problems including crippling arthritis and eye surgery with complications and visual impairment. Her physician feels strongly that any "bad news" should come from him and that he will see her in the morning and begin evaluation of the lung mass. The patient asks what the chest radiograph showed. For a complete compilation of the case examples, please contact Joyce M Mitchell, MD, FACER
p 9-12. 5. American College of Emergency Physicians, Special Committee on the Core Content Revision: Emergency medicine Core Content. Ann
Emerg Med 1986;15:853-862.
6. Culver CM, Clouser KD, Gert B, et al: Basic curricular goals in medical ethics. N Engl J Med 1985;312:253-256.
See r e l a t e d editorial, p 210
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