Making Ethics Education Matter: A Novel Approach for Enhancing Ethics Education in a Medical School

Basic instruction in medical ethics has been viewed as an important component of medical education for more than three decades. However, the logistics of determining when and how such education should occur have proven to be complicated. The authors review past and current postulates regarding bioethics education in medical schools. They then discuss the use of a novel, longitudinal curricular that is designed to strengthen recognition, discernment, and resolution of ethical problems throughout medical training. The model provides both in person and on-line instruction, as well as the option for medical students to obtain a Bioethics Certificate. Quotes from students are used to shed light on the ethical journey that medical students undertake and their enthusiasm for innovative coursework that prepares them for the moral challenges that accompany the provision of healthcare.

Given the inadequate funding for instruction and curricula development coupled with the lack of consensus about subject matter and approach, it is perhaps unsurprising that a growing body of research suggests that the hidden curriculum blunts the impact of the formal curriculum such that students are trained to practice according to what they see and learn from role models rather than what they are taught. (Salzburg, 2014) The risk, in this milieu, is that students may lose focus on the importance of ethics and succumb to pressures to disregard or minimize ethical principles. (Lakhan, Hamlat, McNamee, & Laird, 2009)

Pondering Ethics Education at Sanford School of Medicine
Faculty of Sanford USD School of Medicine (SSOM) believe that students should see ethical judgements as an integral component of a clinician's day, essential when developing a clinical practice that recognizes and values the context of a patient's life. (Cook & Freeman, 2017) While cognizant of the role that theoretical foundations and paradigm cases play in ethics educations, faculty share a deepening appreciation for what scholars term "micro ethics"-the value and judgement issues that are confronted in every day clinical practice. (Troug et al., 2015) Faculty discussions led to the SSOM integrated ethics program, a longitudinal undertaking tailored to the medical school's innovative three pillar system. Pillar 1, an 18 month experience, focuses on foundational biomedical sciences, organ system blocks with limited lectures, interweaved with clinical cases and experiences, early clinical exposure, case-based small groups, and simulation. Pillar 2, a twelve-month experience, offers clinical clerkships in core disciplines that are integrated into longitudinal outpatient experiences. Some students opt to spend Pillar 2 in rural communities, the so-called FARM program (Frontier and Rural Medicine). Pillar 3, the final 18 months, offers required rotations in emergency medicine, rural family medicine, and selected sub-internships, as well as multiple sub-specialty electives. During Pillar III, students have unique opportunities for research, completion of a Certificate in Bioethics, or pursuit of out-of-state and global experiences.
This paper describes the SSOM ethics program, an integrated effort that reflects general recommendations and guidelines for best practices for ethics training in medical education. (Giublini, Milnes, & Savulescu, 2016) When discussing results, we offer the responses of students to demonstrate their experiences with the new program. The quotes from the Pillar 1 students were selected by faculty, using accepted qualitative methodologies, as typical student narrative responses to issues raised during introductory bioethics lectures. The quotes from the Pillar 2 and Pillar 3 students were selected by two ethics faculty who reviewed all of the student responses posted on the online discussion boards that are developed for each course. In each case, the quotes were selected to be representative and illustrative of the ideas offered by students in response to the readings and clinical vignettes under discussion. The guiding framework, when selecting representative quotes, embodied an effort to shed light on themes, concerns, and concepts that seemed relevant and meaningful to students. Notable was the movement from unease and discomfort that Pillar 1 students often expressed when encountering ethical issues to the interest and willingness to respond expressed by the Pillar 2 and Pillar 3 students.
In order to uphold ethical standards, written permission was sought from all students prior to inclusion of their unattributed quotes. Consistent with federal guidelines, this project has been reviewed via procedures of the University of South Dakota Institutional Review Board (IRB). Upon review, the IRB determined the activities were conducted for educational purposes, do not meet the regulatory definition of research, and do not fall under the IRB's purview.

METHODS: DESIGNING AN INTEGRATED ETHICS PROGRAM
For a number of years, the SSOM ethics faculty have used traditional pedagogic strategies like lectures, small group discussions, reflective writing, and individualized study when providing ethics education. In 2016, these approaches were bolstered by the creation of online and distance coursework that could both deepen the program and include students who pursue the FARM, global, or out-of-state options afforded by the SSOM three pillar system. The curriculum that has emerged appears to both enhance ethical awareness and augment the development of skills over time and in diverse -including very rural -settings.

Pillar 1 Ethics Program
All Pillar 1 students explore the topics of medical ethics and professionalism via four 75-minute seminars that employ lectures, small group discussions, and film. The seminars are led by physician role models who can attest to the importance and relevance of the practical issues under consideration. During the initial seminar, students are introduced to a practical model for ethical decisionmaking that was developed in 2005 by the medical school's Section of Ethics and Humanities. The C/CPR model focuses on Covenant, Context, Principles and Resolution and has proven to be a memorable and relevant tool that helps students and practitioners address the obscurity that often accompanies an understanding of the moral and ethical obligations of the profession. (Freeman, Schellinger, Olsen et al., 2005) Covenant is a solemn agreement and bedrock foundation upon which a practical ethics model can reside. The other C/CPR components can then coalesce into a practical and coherent method. Recognition of the context of a patient's life becomes crucial to tailoring appropriate medical responses. (Cook & Freeman, 2017) Once a clinician understands the impact of context, the venerable principles and values championed by Beauchamp, Childress and others can be logically employed. Since the micro-ethics of everyday practice requires a practical interaction with patients, resolution speaks to the actions and words that are chosen or avoided in every day care. Students are encouraged to utilize the C/CPR model to help frame their clinical experiences throughout training.
The second seminar focuses on the practical challenges of decision-making. Students apply the C/CPR model (Covenant, Context, Principles and Resolution) to help resolve a series of patient care scenarios. The third session uses lectures, assigned readings and small group discussions to explore how contextual factors like culture, research, disease status, competing values, and interpersonal relationships influence the plan of care. The fourth session focuses on professional challenges posed by issues like the difficult patient and the impaired physician.
Pillar 1 students can further augment their skills by enrolling in optional courses like "The Healer's Art" course developed by Dr. Rachel Naomi Remen. (Remen) The Pillar 1 ethics program also includes educational sessions and activities that focus on student wellness, emphasizing the ethics of self-care as a crucial aspect of being able to respond to the ethical and social dilemmas posed in patient care.

Pillar 2 Ethics Program
In Pillar 2, all students enroll in a required, 1-credit online Clinical Ethics course that is delivered weekly over a 5 month period of time and reinforces the topics introduced during their Pillar 1 ethics sessions. For this innovative course, the students are divided into four cohorts that are small enough in size to permit meaningful discussion and dialogue. Each cohort is led by a faculty member of the SSOM Section of Ethics and Humanities. Weekly themes provide students the opportunity to reflect upon a wide range of ethical issues and problems such as: the goals of medicine, the context and expectations of health care, patient safety and disclosure of error, patient/clinician relationships, protections when conducting human subject research, translational research, risks and benefits of health interventions, disease prevention and control, rationing and allocation, rural constraints, genetics, biotechnology, conscience, and self-care. Carefully selected weekly readings, clinical vignettes, and discussion questions help students explore how they recognize, analyze, approach, discuss, and resolve ethics-related issues. Throughout each week, students are required to respond to readings, vignettes, and questions by posting their reactions, questions, ideas, and suggestions on their cohort discussion board. Students are asked to engage in meaningful conversations as they respond to their colleagues' posts. The discussion board provides a safe space for students to learn from one another, to reflect, to find the words to describe the issues they face, and to practice what it means to actually engage in peer dialogue about ethical issues (across diverse placement sites) without fear of repercussions. Students are further encouraged to seek opportunities to apply insights to their Pillar 2 clinical experiences and to discuss the readings and vignettes with their attending physicians. Such discussions help move considerations about ethics from the classroom to the bedside. Thus, incrementally over the 5 month time span, the students build conceptual tools and practical experiences that enhance recognition of ethical issues, facilitate discussion among faculty, peers and patients, and integrate ethics into practice. Pillar 2 students also participate in three Friday Academy group sessions, led by physicians and senior medical students that reinforce the lessons and key concepts of the Pillar 2 online ethics course. For group sessions, students at the FARM sites are linked via video conferencing. Pillar 2 students also develop and submit a reflective paper on professionalism. This paper provides an opportunity for students to integrate their Pillar 1 and Pillar 2 experiences, reflecting on where they have been and where they might be going.

Pillar 3 Ethics Program
During Pillar 3, students at multiple clinical sites across the state may take individual on-line ethics electives or opt to complete requirements for the 12-credit Certificate in Bioethics. Since Pillar 3 is an 18 month experience, this coursework affords the involvement of students who are nearing the end of their training as well as students who will graduate in the following year. The certificate's competency-based course of study includes three core courses (9 credits): Advanced Studies in Bioethics, Ethical Foundations for Clinical Research, and Ethics, Professionalism and Leadership; each course is delivered online in intensive three week blocks. Daily assignments include readings, clinical vignettes, and discussion questions. Students are required to engage in an ongoing discussion with each other and with faculty throughout the day. They are asked to monitor, evaluate, and document their decisionmaking processes. For each of the core courses, students are also expected to develop and post for peer review a project that shows integration of the course's concepts and competencies. The three additional credits required for the certificate program are met through the required Pillar 2 Clinical Ethics, and other 1 credit elective courses such as The Healer's Art seminar, Humanities and Medicine, Spirituality and Medicine and Ethical Issues in Medicine (a practicum that features intensive experiences with members of the SSOM Section of Ethics and Humanities). The certificate courses foster adaptive learning as students learn individually and together with peers, teachers, and attending physicians in multiple contexts.

RESULTS: MAKING ETHICS EDUCATION MATTER
Responses from students suggest that the SSOM model is providing a solid ethics education in a manner that student find meaningful and helpful. Students have become increasingly adept at the practical work of ethics as they learn how to ask questions, collaborate with peers, and engage patients, families, and attending physicians in ethics-related discussions. Activities that include reflective writing, discussions of articles and vignettes, and integration of clinical experiences appear to strengthen ethical judgement, critical thinking, and behavioral responses. As students process the course materials, they become adept at recognizing forces that influence their decisions like the impact of the hidden curriculum, their own moral values, or their fears of potential consequences when considering a moral response.
The reflective narratives, submitted by Pillar 1 students suggest a growing appreciation for the role that ethics will play in their professional lives. Responding to the initial seminar on kindness, covenant, and professionalism, one student noted that "the patient contributes gifts of vulnerability, trust, and communication. A physician contributes gifts of knowledge, attentiveness, kindness and protection." Noted another: "After today, I know that developing a relationship with my patients and creating a "covenant" with them is the meaning behind medicine." During the early weeks of the Pillar 2 online Clinical Ethics course, the students' posts on the discussion board often underscore their unease and discomfort in knowing how best to respond when ethics-related issues emerge. Noted one Pillar 2 student: "This feeling of being subservient often makes it difficult to do the right thing when these ethical issues arise." Another explained: "Even if I knew the proper dialogue to use when addressing an ethical issue, I would still be worried about how another person would respond to me identifying an issue. Would they be upset with me? Would my actions be more closely monitored in the future because I addressed concerns about an issue? I think many of us choose to fly under the radar to prevent unwanted scrutiny toward our own actions." Noted another student: "Each one of these scenarios made me feel uncomfortable and feeling like I would not know how to act if (and when) I found myself in them". The students often underscore the value of the reading, reflective writing, and dialogue with one another. During daily discussions, they question and affirm one another, offering advice and support as they ponder and debate when and how they might respond to their clinical experiences. Observed one student: "I wanted to share this with the group because it seems so fitting that once we started discussing ethics in more detail this came up." As the course progresses, the posts from the Pillar 2 Clinical Ethics students show a growing consensus about the value of training in ethics. As one Pillar 2 student noted: "I think these ethical discussions and readings, coupled with proper reflection, will help us construct a moral compass that we can continue to shape and build as we advance through our training." Another student reported that an attending physician asked about the ethics class and remarked that students were "lucky to actually have these topics brought up…and wished that during her medical education they would have talked with them about ethics before they got into practice". The student closed the post by endorsing the need to "take some time to sit back and appreciate how we may have ethically grown throughout this class". Over the five month course, Pillar 2 students become increasingly adept at perceiving the limitations of their own biases, offering statements like "I never viewed the situation from a perspective other than my own;" and "These readings sparked a lot of internal conflict as I reflected on experiences in my clinical education". One student commented on the growing recognition of ethical problems noting that: "Medicine is an art. It is an art of theoretical science blended with life. Remembering medicine as such is essential to its practice." Pillar 2 students seemed particularly appreciative of the unit on the ethics of self-care and openly discussed with one another the challenges of coping with stress, fear, burnout, and their own emotional needs. Noted one student: "We are expected to keep ourselves together even in the midst of emotional and stressful situations and sometimes it seems like those expectations get the best of us. We get so used to putting our heads down and pushing through whatever emotions we are fighting for the day, that we too often forget what it is like to slow down and take time to breathe." By the second month of the 5 month online ethics course, students consistently and more confidently discuss the linkages between the course and their clinical work, reflecting on how the readings and discussions influence their interactions with patients and with attending physicians. Pondering the implications of giving a diagnosis one student noted: "We are treating patients who may have absolutely no idea about what the future holds for their illness. A new diagnosis, even something as simple as dyslipidemia for example, can make a patient's thought process spiral out of control." Approaching the end of the term, a student explained: "Even though ethical dilemmas are challenging and can be quite daunting to handle, I think that by being exposed to these tough clinical scenarios early on in our careers we are able to face these realizations and become better providers." Observed another Pillar 2 student: "The truth of the matter is, whether we want to or not and whether we are qualified or not, physicians are the people put into these ethical dilemmas. Our patients put us in these positions, so we must decide how to act. We need to make the choices regardless of if they are easy or difficult." A closing comment was offered by a student who noted: Our decisions are meant to be a journey, one we navigate by giving and taking and exploring outcomes of our choices. By engaging others in our "navigation" of choices, we may have our eyes opened to another course of action that hadn't occurred to us before." When the Pillar 2 course was first offered, some student resentment was expected as this 5 month online course requires considerable ongoing time and effort. And certainly some medical students lack enthusiasm about the work entailed in an ethics course, viewing such content as potentially less important than the acquisition of other clinical skills. But those who perceive less value in the subject of ethics appear to be a distinct minority. As these more skeptical students consider and process the ideas of their peers, most seem to develop a more positive view of the importance of the topic matter. One skeptic noted that an assigned article had proven helpful when dealing with the challenges of a new rotation. Others, who originally seemed less invested in the subject of ethics, talked about their "reflections," explained that they were revising their firmly held ideas about an ethical issue, or even enrolled in certificate classes. Such actions suggest a level of maturational change in response to the articles, vignettes, and peer discussions.
SSOM is now in year 3 of the integrated ethics curricula. Appreciation and enthusiasm for the coursework have remained high among students enrolled in individual Pillar 3 electives or the entire bioethics certificate program. Pillar 3 students who enrolled in the Advanced Studies in Bioethics course showed increased awareness, skill, and competency as they discussed topics that included: the rights of parents and children, care of adults with and without decision-making capacity, care in special situations and with vulnerable populations, and conflict competence when encountering and resolving ethics-related problems. Students became adept at recognizing the different contextual factors -and different moral interpretations -that can complicate ethical decision making. Students used terms like "enlightening" when describing their discussions with one another. The course seems to encourage moral imagination. Noted one Pillar 3 student: "You've got me thinking more about duties -what duty do we have to the underserved, how much risk is considered acceptable by our society for providing underserved care, what are our duties to local and international service?" Stated another: "I am glad we're having these conversations, because many of our colleagues will never have thought about these topics." In lieu of a final test, creative projects, developed by the students, aptly showed integration of key concepts. research were firmly established. As they gleaned more information, perspectives changed. Noted one student: "I found it interesting to see how the IRB system we have in place is not as infallible of a system as I previously had thought." The posts from Pillar 3 students showed increased insight into the challenges of research design and analysis as they offered statements like: "When thinking about the honesty and accuracy in the field of biomedical research, I come to several different conclusions. I believe that there is the potential to be accurate to the data that you procure from a study, but dishonest from the way the study was designed or how results are configured to promote one's interest;" and "We are so engulfed in our culture that we might not see our own troubling behaviors". Students adeptly integrated notions of covenant, the concept stressed in their 1st ethics session of Pillar 1 into their discussions. When pondering a research protocols, one Pillar 3 student reflected: "Two words stood out to me: covenant(s) and common good, both having subjective meaning but both implying something larger than a simple concept." Student ideas about key research concepts truly evolved over the three weeks during which the class was conducted. Explained one student: "Without a doubt knowledge of the history of research unethics will prompt this future physician to weigh the benefits/harms of clinical research more carefully." Final projects, involving topics like a proposed research study for pain management, a consent form for genetic testing, a consent protocol for adolescent patients, and a diabetes prevention study were a testament to student growth in areas key to the ethical conduct of research.
The third Pillar 3 elective, Ethics, Professionalism, and Leadership, helped Pillar 3 students explore how inter-related aspects of those three domains influence the provision of care in both urban and rural settings. Emphasis is placed on approaches that help physicians assume a leadership role in developing processes for recognizing and resolving ethical dilemmas that challenge the delivery of healthcare. Topics included: exploring the call to covenant, micro and macro ethics consultation, citizenship in the medical community, the role of conscience when providing care, integrating ethics into the organizational culture, managing moral distress and clinician wellness, and exploring controversies in the socioeconomics of healthcare. The value of reflective writing, the growth in student awareness, and the increasing willingness to seek resolution were reflected in the student responses. Noted one: "I seriously need to delve into this [topic] more. It is such a mind boggler for me." Another stated: "It struck me that almost every encounter that I've viewed as "difficult" really was me transferring my feelings about myself onto my patient. So for today's cases. They're all difficult encounters, but mostly because of physician factors. Our own discomfort with a patient, or our reticence to give medical advice to family." When discussing the nexus of leadership and ethics, one student observed: "It is not as though medical students are entering their programs and careers as unethical and corrupt people, but when we see and hear things from our attendings that may cross the line, we learn that this is the way to act in our profession." The integrated ethics coursework seems to help SSOM students expand the ethical lens from a focus on just the patients' illnesses to a focus that includes the self and professional attributes --what it means to be a member of the medical profession and how professional behavior influences the quality of healthcare. Students in the Pillar 1, 2 and