Research Article: Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations

Date Published: May 29, 2019

Publisher: Public Library of Science

Author(s): Maria Fernanda dos Santos, João F. L. Schoueri, Camila T. Vidal, Pedro T. Hamamoto Filho, Fernanda B. Fukushima, Edison I. O. Vidal, Cesario Bianchi.

http://doi.org/10.1371/journal.pone.0217717

Abstract

Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.

The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students’ perspectives.

Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.

There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Partial Text

Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates [1–5]. In 1994 Feudtner et al [6] coined the term “ethical erosion” to denote a process that affects many medical students during their training and which is characterized by the abandonment of certain moral values, changes in attitude and in ethical identity. In alignment with that perception, Leape and colleagues [3,7] made a strong argument that the healthcare field is paved with a diffuse culture of disrespect which plays a central role in the genesis and maintenance of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources [8].

We conducted a national survey of instruments used by Brazilian medical schools to evaluate clerkship rotations from the perspective of medical students. Data collection took place between August 2014 and September 2015. Every medical school that had at least one group of students graduated by the first semester of 2014 was eligible to participate in the survey. In May 2014 there were 176 medical schools in Brazil that fulfilled that criterion.

We provide a summary of the process of selection and invitation of medical schools to participate in the survey in Fig 1. Forty-nine (40.5%) out of 121 schools accepted our invitation to participate in the study. Nonparticipating institutions had lower mean time of functioning when compared with participating institutions (Mean Difference (MD): 35.8 years, 95%CI: 25.5–46.1, P<0.001). There were no statistically significant differences when comparing nonparticipating with participating schools concerning the mean number of vacancies for new first-year students (MD: 15.0, 95% CI: -3.0 to 33.0, P = 0.10) and the proportion of public to private schools (0.71 vs. 0.96, respectively, P = 0.54). To our knowledge this is the first national survey of medical schools in any country focusing specifically on the institutional instruments used to assess the quality of clerkship rotations according to the perspective of medical students. The first relevant finding of our research was that almost half of the participating medical schools did not have any institutional instrument designed to assess the quality of the clerkship rotations according to the perspective of students. That finding is important because it discloses a major missed opportunity to unveil aspects of institutions and of their functioning that could benefit from quality improvement initiatives concerning both medical education and the care of patients. It is especially relevant in the present context where most schools have several rotations taking place outside their institutions. It also represents a wasted chance to communicate students and staff about the most important values and quality models that schools want to nurture within their domains in a more concrete manner than through institutional discourses.   Source: http://doi.org/10.1371/journal.pone.0217717

 

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