2015, 37: 228–231
HOW WE. . .
How we involved rural clinicians in teaching ethics to medical students on rural clinical placements LISA PARKER & LISA D. WATTS University of New South Wales, Australia
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Abstract Background: The task of engaging senior medical students in ethical inquiry while on rural clinical placements has received minimal attention in the medical education literature. As there is an international trend for medical students to undertake part or all of their clinical training in rural areas, the need to deliver clinically relevant ethics teaching in a sustainable manner has emerged as a challenge for medical schools. Clinicians tend to be hesitant about delivering this kind of teaching. What we did: We introduced a novel teaching program which involved recruiting, training and supporting experienced rural clinicians to facilitate a series of Rural Ethics Ward Rounds with the senior medical students on extended rural placements. Evaluation: The clinical facilitators expressed some initial uncertainty with the teaching model, but generally reported a positive experience, including significant professional benefits such as increased ethical awareness and opportunity for self-reflection. Conclusion: This model enables experienced rural clinicians to facilitate student development in ethical awareness and skill, and requires relatively low demands on academic time and resources.
Introduction
Practice points
There has been much progress in curriculum development and teaching innovation within the broad field of medical ethics education, yet the question of how and by whom clinical ethics should be taught remains a particular challenge for medical schools. There is growing recognition of the need for clinically situated ‘real-world’ teaching (Lipworth et al. 2012) and a number of published studies describe and analyse the effectiveness of various models of teaching clinical ethics (Fryer-Edwards et al. 2006; Kaldjian et al. 2012). The context for these programs, however, is almost always large, wellresourced, urban teaching hospitals. As medical education expands into increasingly more diverse health settings and particularly into rural and remote areas, so too does medical ethics education need to keep pace with these changes (Brooks et al. 2012). There is much common ground between ethical issues that arise in urban and rural clinical settings, yet in rural areas there are additional considerations. A greater focus may be needed on issues like the management of dual-relationships and professional boundaries (Birden & Usherwood 2013), confidentiality and stigma, tele-medicine and its impact on the doctor-patient relationship, working with the constraints of workforce shortages and limited patient access to healthcare (Nelson et al. 2007; Klugman & Dalinis 2008). Ethics educators may also need to deal with students being more dispersed and the relative shortage of locally-based content specialists.
Rural doctors with considerable clinical experience require minimal ethics training to be confident ethics facilitators Student-centred, ‘no right answer’ approach is a suitable ethics teaching model for clinical teachers Clinicians report increased ethical awareness and reflection as a result of facilitating
Our initial strategy to teach clinical ethics to students on rural placements was the development of Rural Ethics Ward Rounds (REWRs), using video-conferencing technology to enable an urban-based tutor with ethics-content expertise to engage regularly with four groups of rurally-based students in case presentation sessions. The format of the sessions involved student identification and presentation of cases with a clinical ethics dimension from their recent clinical experiences, followed by a tutor-facilitated discussion amongst the students to share ideas and opinions about the ethical issue and possible management strategies. The teaching pedagogy underpinning the REWR model has been described in detail elsewhere, along with student evaluation of the course (Parker et al. 2012; Watts et al. 2013). The model assumes a basic theoretical knowledge of ethics theory amongst the students and concentrates upon the development of important skills in clinical ethics.
Correspondence: Lisa Watts, Faculty of Medicine, Rural Clinical School, Sydney Campus, University of New South Wales, Samuels Building, Level 3, room 327, NSW 2052, Australia. Tel: +61 (2) 9385 2922; Fax: +61 (2) 9385 1970; E-mail: [email protected]
228
ISSN 0142-159X print/ISSN 1466-187X online/15/030228–4 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.923559
Rural clinicians teaching ethics
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
It was clear to us from the outset of the REWR project that the teaching load on one individual would not be sustainable and so the second stage of this project involved a trial of recruiting, training and supporting local, rural clinicians to facilitate the REWRs, followed up by evaluation of the new format. Evaluation was done using semi-structured interviews and a joint ‘de-briefing’ session of the clinicians at the conclusion of the REWR sessions (Sturman et al. 2011). Detailed notes were taken from these evaluation sessions and analysis of themes regarding any difficulties, successes and suggested changes was conducted independently by each author using a modified Framework methodology (Ritchie 1994). Results were compared and thematic agreement was reached.
How we involved rural clinicians in teaching clinical ethics With the help of the Heads of each campus, we identified five experienced clinicians with an interest in ethics to be facilitators at our four rural campuses. Each of the clinicians took on the Facilitator role in addition to their other part-time clinical teaching responsibilities and were given a half-day training session, extensive reading material and ongoing supervision and academic support as required. Each of the clinicians ran between four and six sessions with up to 15 senior students in each group. Most of the sessions were held over concurrent weeks, while one facilitator timetabled the sessions over a three month period in order to capture greater clinical and ethical diversity from the different student rotations. The training day provided an overview of content from the ethics curriculum to ensure that facilitators were familiar with major influences in clinical ethics including theories and legal cases, and also served as a refresher course for reflective thinking and reasoned debate. We communicated and modelled that the REWR model is student centred, emphasising peer discussion and learning about multiple perspectives, and that facilitators should guide discussion and draw on their extensive clinical experience but are not expected to be ethics experts. Our clinicians initially expressed some concerns about their competency to facilitate in clinical ethics although two of the four facilitators reported having some (limited) post-graduate training in medical ethics. This fits with the literature, which suggests many clinicians feel some reticence about teaching in clinical ethics (Parker et al. 1997; Eckles et al. 2005). Encouraged by Peter Singer and others (Singer et al. 2001; Cordingley et al. 2007) who suggest that one of the main roles of a medical ethics expert is to train others to teach in this field, we were hopeful that a combination of careful selection of experienced clinicians together with some basic ethics training and a teaching format that concentrated more on skill enhancement than knowledge transfer, would make the concerns of our facilitators unfounded. Indeed this proved to be the case, and facilitator feedback revealed that all of our clinicians were content that their theoretical knowledge had been sufficient for the task and that the brief teacher training
together with their own clinical experience enabled them to facilitate the sort of skill development that we were interested in, including self reflection, communication and conflict resolution. The nature of the teaching sessions and the rural settings led us to anticipate the possibility of students commenting on what they perceive to be unethical conduct in other professionals so a key concern within our project was to provide the facilitators with skills and strategies to respond to any student reports of unprofessional behaviour amongst staff. We suggested to facilitators that many student concerns may arise from inexperience in the clinical setting and that facilitators should explore possible misunderstandings within the group discussion. We also noted that while vindictive comments should certainly not be tolerated, it would be important to listen to student concerns about behaviour in others as a means of validating unease about lapses of professionalism or unethical conduct, even when cases relate to seemingly minor issues such as poor time-keeping or mildly inappropriate humour. Finally, the possibility of cases relating to serious misconduct was discussed and it was recognised as a particularly sensitive matter for facilitators working and living in an inter-dependent rural community. Brooks et al. (2012) in their study of rural clinical practice note that, ‘the limited choices that come with increased isolation raise the risk that poor practice and ethical violations will be overlooked or tolerated’. Possible plans of action were discussed (Bloch 2003) and facilitators were aware that senior academic staff were readily available for specific advice or support if needed. Facilitators reported that such issues were indeed raised. All the facilitators used a ‘no name’ policy for both patients and staff when discussing ethically sensitive cases, but inevitably, ‘everyone in the room knows who they are talking about’. Despite this, the facilitators felt well prepared to deal with the issue, and didn’t feel that it impacted upon the teaching: In a small place like this whenever they talk about a specialist or a patient even, it can easily be that I know that person because we all know each other here . . . It is definitely more difficult in a rural setting than in the city . . . It can get very close to home and must be handled sensitively, but there wasn’t anything that we couldn’t handle. The facilitators reported that the novel style and structure of the REWR was challenging for them. They were unfamiliar with the lack of teaching plan, and a format where ‘anything [could] come up’. All found that they needed to make conscious efforts to avoid ‘teaching’, instead practicing listening, encouraging and, hardest of all, waiting through silences, to allow students time to think and speak. To a certain extent this was exacerbated by the students, who were also unfamiliar with the ‘no right answers’ style of ethical discourse. You feel that the students want answers from you . . . it was a different way . . . To try and get them to discuss rather than give a lecture.
229
L. Parker & L. D. Watts
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Our facilitators offered a variety of strategies they used to manage this, including appointing specific students in advance to find a case for discussion; selecting a specific ethics topic in advance, or preparing some ‘back-up’ cases from their own recent clinical experience. In any subsequent training sessions for new facilitators, we will incorporate these suggestions. We learnt from our facilitators that they had few formal opportunities themselves to discuss ethical issues in their dayto-day practice, with informal networks of spouses and colleagues being their main resource. REWR facilitation provided them with a regular opportunity to engage with a variety of ethically alert trainees, and they were pleasantly surprised at how useful this was (Fryer-Edwards et al. 2006; Wiggleton et al. 2010). They also reported increased ethical awareness for their own practice:
teaching rounds themselves. It was pleasing to note that all facilitators quickly developed confidence in delivering this format. We did benefit from personal recommendation about potential facilitators, and would encourage others to take similar care in the selection of suitable clinical candidates.
Notes on contributors Dr LISA PARKER, MMed, MA, is a Lecturer in Bioethics, School of Public Health & Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. LISA WATTS, Med, is a Research Officer, Rural Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
Acknowledgements For me, you reflect on the cases they talk about and think, ‘what would I have done’ and it makes you more aware and you see more potential scenarios in your own clinical work. It is definitely positive for the facilitator. The benefits for the facilitators were extremely pleasing to hear and will certainly be something we would emphasise when recruiting new facilitators in the future. Our model was piloted within the rural teaching setting and although it has particular value in this ethicsresource-poor context, it is readily amenable for use within an urban clinical school. Students report they regard clinicians as the most appropriate source of professional guidance in matters of ethics and professionalism (Singer et al. 2001; Cordingley et al. 2007) and providing dedicated teaching time for this purpose ensures that these important issues do not get overlooked or lost amidst the mass of other clinical learning that must take place (Parker et al. 2012).
What’s next Our facilitators reported that by focusing on the difficult edges of rural clinical practice, the REWR enabled them to promote greater understanding of the realities of rural working life and thus better prepare their students for their current and future roles in rural healthcare. We are interested in exploring this topic in the future, and will seek further evaluation data from students as to whether they find the REWR helpful in dealing with the stress of being a medical student on a rural clinical placement.
Conclusion Our REWRs aim to build upon ad hoc teaching and use a more formalised educational approach to facilitate student maturation into ethical practitioners. This teaching model was developed with general clinicians in mind as facilitators, and has relatively low demands on academic time and resources, requiring only a short training session in addition to the 230
The authors wish to thank the Ethics Facilitators for their time and valuable contributions to this project, and Dr Lesley Forster and the staff of the UNSW Rural Clinical School, for their co-operation and support. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This study was approved by the Medical and Community Human Research Ethics Advisory Panel of the University of New South Wales (2012-7/07).
References Birden H, Usherwood T. 2013. ‘They liked it if you said you cried’: How medical students perceive the teaching of professionalism. Med J Aust 199:406–409. Bloch S. 2003. Medical students and clinical ethics. Med J Aust 1784: 167–169. Brooks KD, Eley DS, Pratt R, Zink T. 2012. Management of professional boundaries in rural practice. Acad Med 878:1091–1095. Cordingley L, Hyde C, Peters S, Vernon B, Bundy C. 2007. Undergraduate medical students’ exposure to clinical ethics: A challenge to the development of professional behaviours? Med Educ 4112:1202–1209. Eckles RE, Meslin EMP, Gaffney MMD, Helft PRMD. 2005. Medical ethics education: Where are we? Where should we be going? A review. [Report]. Acad Med 8012:1143–1152. Fryer-Edwards K, Wilkins MD, Baernstein A, Braddock 3rd CH. 2006. Bringing ethics education to the clinical years: Ward ethics sessions at the University of Washington. Acad Med 817: 626–631. Kaldjian LC, Rosenbaum ME, Shinkunas LA, Woodhead JC, Antes LM, Rowat JA, Forman-Hoffman VL. 2012. Through students’ eyes: Ethical and professional issues identified by third-year medical students during clerkships. J Med Ethics 38:130–132. Klugman CM, Dalinis PM. 2008. Ethical issues in rural healthcare. Baltimore, MD: Johns Hopkins University Press. Lipworth W, Kerridge I, Little M, Gordon J, Markham P. 2012. Meaning and value in medical school curricula. J Eval Clin Practice 185: 1027–1035. Nelson WA, Pomerantz A, Howard K, Bushy A. 2007. A proposed rural healthcare ethics agenda. J Med Ethics 333:136–139. Parker L, Watts L, Scicluna H. 2012. Clinical ethics ward rounds: Building on the core curriculum. J Med Ethics 38:501–505. Parker MH, Price DA, Harris PG. 1997. Teaching of medical ethics: Implications for an integrated curriculum. Med Educ 313:181–187.
Rural clinicians teaching ethics
Watts L, Parker L, Scicluna H. 2013. Rural ethics ward rounds: Enhancing medical students’ ethical awareness in rural medicine. Aust J Rural Health 212:128–129. Wiggleton C, Petrusa E, Loomis K, Tarpley J, Tarpley M, O’Gorman ML, Miller B. 2010. Medical students’ experiences of moral distress: Development of a web-based survey. Acad Med 851: 111–117.
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Ritchie J. 1994. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing qualitative data. London; New York: Routledge. pp 173–194. Singer PA, Pellegrino ED, Siegler M. 2001. Clinical ethics revisited. BMC Med Ethics 2:1–8. Sturman N, Re´go P, Dick ML. 2011. Rewards, costs and challenges: The general practitioner’s experience of teaching medical students. Med Educ 457:722–730.
231
HOW WE. . .
How we involved rural clinicians in teaching ethics to medical students on rural clinical placements LISA PARKER & LISA D. WATTS University of New South Wales, Australia
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Abstract Background: The task of engaging senior medical students in ethical inquiry while on rural clinical placements has received minimal attention in the medical education literature. As there is an international trend for medical students to undertake part or all of their clinical training in rural areas, the need to deliver clinically relevant ethics teaching in a sustainable manner has emerged as a challenge for medical schools. Clinicians tend to be hesitant about delivering this kind of teaching. What we did: We introduced a novel teaching program which involved recruiting, training and supporting experienced rural clinicians to facilitate a series of Rural Ethics Ward Rounds with the senior medical students on extended rural placements. Evaluation: The clinical facilitators expressed some initial uncertainty with the teaching model, but generally reported a positive experience, including significant professional benefits such as increased ethical awareness and opportunity for self-reflection. Conclusion: This model enables experienced rural clinicians to facilitate student development in ethical awareness and skill, and requires relatively low demands on academic time and resources.
Introduction
Practice points
There has been much progress in curriculum development and teaching innovation within the broad field of medical ethics education, yet the question of how and by whom clinical ethics should be taught remains a particular challenge for medical schools. There is growing recognition of the need for clinically situated ‘real-world’ teaching (Lipworth et al. 2012) and a number of published studies describe and analyse the effectiveness of various models of teaching clinical ethics (Fryer-Edwards et al. 2006; Kaldjian et al. 2012). The context for these programs, however, is almost always large, wellresourced, urban teaching hospitals. As medical education expands into increasingly more diverse health settings and particularly into rural and remote areas, so too does medical ethics education need to keep pace with these changes (Brooks et al. 2012). There is much common ground between ethical issues that arise in urban and rural clinical settings, yet in rural areas there are additional considerations. A greater focus may be needed on issues like the management of dual-relationships and professional boundaries (Birden & Usherwood 2013), confidentiality and stigma, tele-medicine and its impact on the doctor-patient relationship, working with the constraints of workforce shortages and limited patient access to healthcare (Nelson et al. 2007; Klugman & Dalinis 2008). Ethics educators may also need to deal with students being more dispersed and the relative shortage of locally-based content specialists.
Rural doctors with considerable clinical experience require minimal ethics training to be confident ethics facilitators Student-centred, ‘no right answer’ approach is a suitable ethics teaching model for clinical teachers Clinicians report increased ethical awareness and reflection as a result of facilitating
Our initial strategy to teach clinical ethics to students on rural placements was the development of Rural Ethics Ward Rounds (REWRs), using video-conferencing technology to enable an urban-based tutor with ethics-content expertise to engage regularly with four groups of rurally-based students in case presentation sessions. The format of the sessions involved student identification and presentation of cases with a clinical ethics dimension from their recent clinical experiences, followed by a tutor-facilitated discussion amongst the students to share ideas and opinions about the ethical issue and possible management strategies. The teaching pedagogy underpinning the REWR model has been described in detail elsewhere, along with student evaluation of the course (Parker et al. 2012; Watts et al. 2013). The model assumes a basic theoretical knowledge of ethics theory amongst the students and concentrates upon the development of important skills in clinical ethics.
Correspondence: Lisa Watts, Faculty of Medicine, Rural Clinical School, Sydney Campus, University of New South Wales, Samuels Building, Level 3, room 327, NSW 2052, Australia. Tel: +61 (2) 9385 2922; Fax: +61 (2) 9385 1970; E-mail: [email protected]
228
ISSN 0142-159X print/ISSN 1466-187X online/15/030228–4 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.923559
Rural clinicians teaching ethics
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
It was clear to us from the outset of the REWR project that the teaching load on one individual would not be sustainable and so the second stage of this project involved a trial of recruiting, training and supporting local, rural clinicians to facilitate the REWRs, followed up by evaluation of the new format. Evaluation was done using semi-structured interviews and a joint ‘de-briefing’ session of the clinicians at the conclusion of the REWR sessions (Sturman et al. 2011). Detailed notes were taken from these evaluation sessions and analysis of themes regarding any difficulties, successes and suggested changes was conducted independently by each author using a modified Framework methodology (Ritchie 1994). Results were compared and thematic agreement was reached.
How we involved rural clinicians in teaching clinical ethics With the help of the Heads of each campus, we identified five experienced clinicians with an interest in ethics to be facilitators at our four rural campuses. Each of the clinicians took on the Facilitator role in addition to their other part-time clinical teaching responsibilities and were given a half-day training session, extensive reading material and ongoing supervision and academic support as required. Each of the clinicians ran between four and six sessions with up to 15 senior students in each group. Most of the sessions were held over concurrent weeks, while one facilitator timetabled the sessions over a three month period in order to capture greater clinical and ethical diversity from the different student rotations. The training day provided an overview of content from the ethics curriculum to ensure that facilitators were familiar with major influences in clinical ethics including theories and legal cases, and also served as a refresher course for reflective thinking and reasoned debate. We communicated and modelled that the REWR model is student centred, emphasising peer discussion and learning about multiple perspectives, and that facilitators should guide discussion and draw on their extensive clinical experience but are not expected to be ethics experts. Our clinicians initially expressed some concerns about their competency to facilitate in clinical ethics although two of the four facilitators reported having some (limited) post-graduate training in medical ethics. This fits with the literature, which suggests many clinicians feel some reticence about teaching in clinical ethics (Parker et al. 1997; Eckles et al. 2005). Encouraged by Peter Singer and others (Singer et al. 2001; Cordingley et al. 2007) who suggest that one of the main roles of a medical ethics expert is to train others to teach in this field, we were hopeful that a combination of careful selection of experienced clinicians together with some basic ethics training and a teaching format that concentrated more on skill enhancement than knowledge transfer, would make the concerns of our facilitators unfounded. Indeed this proved to be the case, and facilitator feedback revealed that all of our clinicians were content that their theoretical knowledge had been sufficient for the task and that the brief teacher training
together with their own clinical experience enabled them to facilitate the sort of skill development that we were interested in, including self reflection, communication and conflict resolution. The nature of the teaching sessions and the rural settings led us to anticipate the possibility of students commenting on what they perceive to be unethical conduct in other professionals so a key concern within our project was to provide the facilitators with skills and strategies to respond to any student reports of unprofessional behaviour amongst staff. We suggested to facilitators that many student concerns may arise from inexperience in the clinical setting and that facilitators should explore possible misunderstandings within the group discussion. We also noted that while vindictive comments should certainly not be tolerated, it would be important to listen to student concerns about behaviour in others as a means of validating unease about lapses of professionalism or unethical conduct, even when cases relate to seemingly minor issues such as poor time-keeping or mildly inappropriate humour. Finally, the possibility of cases relating to serious misconduct was discussed and it was recognised as a particularly sensitive matter for facilitators working and living in an inter-dependent rural community. Brooks et al. (2012) in their study of rural clinical practice note that, ‘the limited choices that come with increased isolation raise the risk that poor practice and ethical violations will be overlooked or tolerated’. Possible plans of action were discussed (Bloch 2003) and facilitators were aware that senior academic staff were readily available for specific advice or support if needed. Facilitators reported that such issues were indeed raised. All the facilitators used a ‘no name’ policy for both patients and staff when discussing ethically sensitive cases, but inevitably, ‘everyone in the room knows who they are talking about’. Despite this, the facilitators felt well prepared to deal with the issue, and didn’t feel that it impacted upon the teaching: In a small place like this whenever they talk about a specialist or a patient even, it can easily be that I know that person because we all know each other here . . . It is definitely more difficult in a rural setting than in the city . . . It can get very close to home and must be handled sensitively, but there wasn’t anything that we couldn’t handle. The facilitators reported that the novel style and structure of the REWR was challenging for them. They were unfamiliar with the lack of teaching plan, and a format where ‘anything [could] come up’. All found that they needed to make conscious efforts to avoid ‘teaching’, instead practicing listening, encouraging and, hardest of all, waiting through silences, to allow students time to think and speak. To a certain extent this was exacerbated by the students, who were also unfamiliar with the ‘no right answers’ style of ethical discourse. You feel that the students want answers from you . . . it was a different way . . . To try and get them to discuss rather than give a lecture.
229
L. Parker & L. D. Watts
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Our facilitators offered a variety of strategies they used to manage this, including appointing specific students in advance to find a case for discussion; selecting a specific ethics topic in advance, or preparing some ‘back-up’ cases from their own recent clinical experience. In any subsequent training sessions for new facilitators, we will incorporate these suggestions. We learnt from our facilitators that they had few formal opportunities themselves to discuss ethical issues in their dayto-day practice, with informal networks of spouses and colleagues being their main resource. REWR facilitation provided them with a regular opportunity to engage with a variety of ethically alert trainees, and they were pleasantly surprised at how useful this was (Fryer-Edwards et al. 2006; Wiggleton et al. 2010). They also reported increased ethical awareness for their own practice:
teaching rounds themselves. It was pleasing to note that all facilitators quickly developed confidence in delivering this format. We did benefit from personal recommendation about potential facilitators, and would encourage others to take similar care in the selection of suitable clinical candidates.
Notes on contributors Dr LISA PARKER, MMed, MA, is a Lecturer in Bioethics, School of Public Health & Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia. LISA WATTS, Med, is a Research Officer, Rural Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
Acknowledgements For me, you reflect on the cases they talk about and think, ‘what would I have done’ and it makes you more aware and you see more potential scenarios in your own clinical work. It is definitely positive for the facilitator. The benefits for the facilitators were extremely pleasing to hear and will certainly be something we would emphasise when recruiting new facilitators in the future. Our model was piloted within the rural teaching setting and although it has particular value in this ethicsresource-poor context, it is readily amenable for use within an urban clinical school. Students report they regard clinicians as the most appropriate source of professional guidance in matters of ethics and professionalism (Singer et al. 2001; Cordingley et al. 2007) and providing dedicated teaching time for this purpose ensures that these important issues do not get overlooked or lost amidst the mass of other clinical learning that must take place (Parker et al. 2012).
What’s next Our facilitators reported that by focusing on the difficult edges of rural clinical practice, the REWR enabled them to promote greater understanding of the realities of rural working life and thus better prepare their students for their current and future roles in rural healthcare. We are interested in exploring this topic in the future, and will seek further evaluation data from students as to whether they find the REWR helpful in dealing with the stress of being a medical student on a rural clinical placement.
Conclusion Our REWRs aim to build upon ad hoc teaching and use a more formalised educational approach to facilitate student maturation into ethical practitioners. This teaching model was developed with general clinicians in mind as facilitators, and has relatively low demands on academic time and resources, requiring only a short training session in addition to the 230
The authors wish to thank the Ethics Facilitators for their time and valuable contributions to this project, and Dr Lesley Forster and the staff of the UNSW Rural Clinical School, for their co-operation and support. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This study was approved by the Medical and Community Human Research Ethics Advisory Panel of the University of New South Wales (2012-7/07).
References Birden H, Usherwood T. 2013. ‘They liked it if you said you cried’: How medical students perceive the teaching of professionalism. Med J Aust 199:406–409. Bloch S. 2003. Medical students and clinical ethics. Med J Aust 1784: 167–169. Brooks KD, Eley DS, Pratt R, Zink T. 2012. Management of professional boundaries in rural practice. Acad Med 878:1091–1095. Cordingley L, Hyde C, Peters S, Vernon B, Bundy C. 2007. Undergraduate medical students’ exposure to clinical ethics: A challenge to the development of professional behaviours? Med Educ 4112:1202–1209. Eckles RE, Meslin EMP, Gaffney MMD, Helft PRMD. 2005. Medical ethics education: Where are we? Where should we be going? A review. [Report]. Acad Med 8012:1143–1152. Fryer-Edwards K, Wilkins MD, Baernstein A, Braddock 3rd CH. 2006. Bringing ethics education to the clinical years: Ward ethics sessions at the University of Washington. Acad Med 817: 626–631. Kaldjian LC, Rosenbaum ME, Shinkunas LA, Woodhead JC, Antes LM, Rowat JA, Forman-Hoffman VL. 2012. Through students’ eyes: Ethical and professional issues identified by third-year medical students during clerkships. J Med Ethics 38:130–132. Klugman CM, Dalinis PM. 2008. Ethical issues in rural healthcare. Baltimore, MD: Johns Hopkins University Press. Lipworth W, Kerridge I, Little M, Gordon J, Markham P. 2012. Meaning and value in medical school curricula. J Eval Clin Practice 185: 1027–1035. Nelson WA, Pomerantz A, Howard K, Bushy A. 2007. A proposed rural healthcare ethics agenda. J Med Ethics 333:136–139. Parker L, Watts L, Scicluna H. 2012. Clinical ethics ward rounds: Building on the core curriculum. J Med Ethics 38:501–505. Parker MH, Price DA, Harris PG. 1997. Teaching of medical ethics: Implications for an integrated curriculum. Med Educ 313:181–187.
Rural clinicians teaching ethics
Watts L, Parker L, Scicluna H. 2013. Rural ethics ward rounds: Enhancing medical students’ ethical awareness in rural medicine. Aust J Rural Health 212:128–129. Wiggleton C, Petrusa E, Loomis K, Tarpley J, Tarpley M, O’Gorman ML, Miller B. 2010. Medical students’ experiences of moral distress: Development of a web-based survey. Acad Med 851: 111–117.
Med Teach Downloaded from informahealthcare.com by University of Waterloo on 03/03/15 For personal use only.
Ritchie J. 1994. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing qualitative data. London; New York: Routledge. pp 173–194. Singer PA, Pellegrino ED, Siegler M. 2001. Clinical ethics revisited. BMC Med Ethics 2:1–8. Sturman N, Re´go P, Dick ML. 2011. Rewards, costs and challenges: The general practitioner’s experience of teaching medical students. Med Educ 457:722–730.
231
