Postgraduate ethics training programs: a systematic scoping review

Background Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum. Methods With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review. Results The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF). Conclusions Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-021-02644-5.

In 12 years, 1,272 students (282 groups) completed the clerkship. Although presentations sometimes address two or more issues, Table 1 indicates the major or primary issue listed for each presentation. As can be seen, informed consent, termination of pregnancy, maternal-fetal conflict, right to refuse treatment, and assisted reproduction were the most frequently addressed individual topics. These echo the experience of Cain et al., aside from more frequent discussions of assisted reproduction, which reflects the increased usage of these technologies since the early 1990s. Most discussions involved obstetrics patients (80%), and about half of these (40% overall) concerned issues specific to obstetrics such as maternal-fetal conflicts and abortion; whereas in the other half, the contextual issues were nonspecific but more complex owing to the pregnancy. A relatively small percentage of student-selected cases (15%) focused primarily on social, cultural, or economic issues such as barriers in communicating with non-English-speaking patients or cultural differences in gender relationships (e.g., a pregnant woman who abdicates all decision making to her husband). However, even when an ethical issue was considered primary, students identified socioeconomic and cultural factors as coissues in the majority of cases: for example, insurance coverage (an economic concern) for in vitro fertilization or abortion (ethical concerns).
In summary, the MCS window of opportunity provides our students with a "booster shot" of personal, ethical, and social awareness in obstetricsgynecological care during the clerkship experience, a period during which they are primed for rapid professional growth; and it helps them resist the reductionistic approach to obstetrics and gynecology promoted by today's fastpaced hospital practice.
What is empathy, and how can it be promoted during clinical clerkships?

Benbassat & Baumal 2011
Descriptive NA NA The authors describe patient interviewing style that facilitates empathy and some practice habits that interfere with it.
The ability of medical students to empathize often declines as they progress through the curriculum. This suggests that there is a need to promote empathy toward patients during the clinical clerkships. In this article, the authors attempt to identify the patient interviewing style that facilitates empathy and some practice habits that interfere with it.
The authors maintain that (1) empathy is a multistep process whereby the doctor's awareness of the patient's concerns produces a sequence of emotional engagement, compassion, and an urge to help the patient; and (2) the first step in this process-the detection of the patient's concerns-is a teachable skill. The authors suggest that this step is facilitated by (1) conducting a "patient-centered" interview, thereby creating an atmosphere that encourages patients to share their concerns, (2) enquiring further into these concerns, and (3) recording them in the section traditionally reserved for the patient's "chief complaint." Some practice habits may discourage patients from sharing their concerns, such as (1) writing up the history during patient interviewing, (2) focusing too early on the chief complaint, and (3) performing a complete system review. The ethical practice of medicine has always been of utmost importance, and plastic surgery is no exception. The literature is devoid of information on the teaching of ethics and professionalism in plastic surgery. In light of this, a survey was sent to ascertain the status of ethics training in plastic surgery residencies.
A total of 104 members responded to the survey (58% response rate). Sixty-three percent were program directors, and most (89%) practiced in academic settings. Sixty-two percent in academics reported having a formal training program, and 60% in private practice reported having one. Only 40% of programs with fewer than 10 residents had ethics training, whereas 78% of programs with more than 20 residents did. The odds of having a training program were slightly higher (odds ratio, 1.1) with more residents (P = 0.17).
Despite the lack of information in the literature, formal ethics and professionalism training does exist in many plastic surgery residencies, although barriers to implementation do exist. Plastic surgery leadership should be involved in the development of standardized curricula to help overcome these barriers. Of the topics encountered in practice by at least two-thirds of pediatricians, more than twothirds of the respondents stated that residency training adequately prepared them to address issues of consent, privacy, truth-telling, and child abuse/neglect, but less than onethird felt adequately prepared to address conduct on social media and requests for prescriptions by family, friends, and colleagues outside of clinical encounters.
As pediatric residency programs adopt more structured curricula for ethics and professionalism education, issues commonly faced by practitioners should be incorporated.
Teaching and assessing ethics in the newborn ICU

Cummings 2016
Review NA NA Ethics and professionalism education has become increasingly recognized as important and incorporated into graduate medical education. However, such education has remained largely unstructured and understudied in neonatology. Neonatal-perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills, and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies.
This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency in neonatology. Finally, the need for consensus and future research in these domains is also highlighted.
Appropriate assessment is crucial to drive further learning. Just as evidence for the best pedagogical methods to teach ethics and professionalism are lacking in neonatology, evidence for optimal strategies for assessment in these areas are also lacking. As discussed above, many neonatal-perinatal training programs and their associated Clinical Competency Committees (CCC) have largely struggled with how best to assess competencies, milestones, and EPAs, particularly those related to ethics and professionalism. Yet, despite existing challenges, assessment in these domains is A "flipped classroom" approach to teaching medical ethics and professionalism in neonatology may be effective, in which students learn course material online via multimedia modules on their own time, then come to class sessions prepared to engage in a variety of educational activities, including in-depth group discussion, enacted role-play, and simulation. This model would engage students with various preferred learning styles, and enable mastery of both knowledge and practical skills in ethics and professionalism during training when time is scarce. Our impossible without some type of measurement.
group is in the process of piloting such an innovative ethics and professionalism curriculum for neonatalperinatal fellows, as well as developing and validating 2 assessment tools. Outcomesbased research is still needed to determine optimal teaching methods as well as assessment strategies in ethics and professionalism in neonatology to ensure trainees not only achieve competency in these domains, but also to ensure the formation of professional, virtuous clinicians with excellent moral and ethical reasoning skills for the ultimate benefit of the patients and their families.  (2) researchers want to answer "how" and "why" questions in addition to determining what is happening in the situation under study. Specifically, we conducted an instrumental case study because we were using the cases (the programs) to gain insight into the issue of the potential divergences between the formal, informal, and hidden ethics curricula rather than evaluating the specific programs themselves. We also decided to conduct a multiple rather than single-case study because we wanted to gain in-depth understanding of the issue by comparing data from two very different contexts that were likely to shape study participants' experiences and views on ethics training in their Programs.
We aimed to compare and contrast the content of the formal, informal, and hidden ethics curricula in two demographically different postgraduate psychiatry programs (hereafter program 1 and program 2) and to explain potential divergences between the three curricula. To achieve these aims, we compared findings from three sources of data: individual interviews with residents and with faculty and relevant documents from each program. This in-depth qualitative study serves as a useful empirical complement to the existing conceptual work on the hidden curriculum in ethics, which lays out, on theoretical grounds, the high-level values embedded within the culture of the medical profession that motivate the hidden curriculum Divergences occurred between the curricula for each topic. The nature of these divergences differed according to local program characteristics. Yet, in both programs, choices for action in ethically challenging situations were mediated by a minimum standard of ethics that led individuals to avoid trouble even if this meant their behavior fell short of the accepted ideal.
Effective ethics education in postgraduate psychiatry training will require addressing the hidden curriculum. In addition to profession-wide efforts to articulate high-level values, program-specific action on locally relevant issues constitutes a necessary mechanism for handling the impact of the hidden curriculum.
The hidden curriculum, ethics teaching, and the structure of medical education.

Hafferty & Franks 1994
Qualitative NA 19 The authors raise questions regarding the widespread calls to intensify the teaching of medical ethics within the medical school curriculum.
In this article we explore the relationship between the formal and the informal teaching of medical ethics during medical training. We also examine-albeit more indirectly-how three beliefs, described below, serve to marginalize ethics in the culture of medicine.
If the arguments advanced above have merit, then it follows that the teaching of ethical principles in the medical school curriculum should be approached and framed quite differently from the teaching of other basic science subjects.
Those who each students need to become more aware of the perceptions of initiates, particularly those at the earliest stages of their training. We conducted a literature review using Medline and Ovid databases. Our initial search retrieved 58 articles using conjunctive searches of the terms "surgery," "ethics education," "residents," and "surgical residents." We substituted our search using the search terms "clerkship," "residency," "medical ethics," "general surgery residency programs," "postgraduate surgical residency," and "graduate medical ethics education." We excluded articles that discussed professionalism primarily (except those that seemed to pertain specifically to the ethical aspects of professionalism); technical training; issues specific to practicing surgeons, rather than surgical residents; and those otherwise beyond the scope of our selected topic of ethics education within US surgical postgraduate residency programs. A second conjunctive search was performed using "surgery," "residency," "end of life care," "palliative care," and "communication." This search retrieved 22 articles. We also searched the references of all identified papers and obtained all published articles, web content, and abstracts that seemed relevant to our topic. Here, we summarize the results of this review.

Ethics
postgraduate surgical training programs.
when integrated in surgical residency curricula, can lead to measurable improvements in resident-centered outcomes, which include knowledge and confidence in handling ethical dilemmas. These curricula may lead to improvements in patient care.
residents is valuable but that questions regarding the optimal "dose" of ethics education and training as well as the optimal teaching methods would benefit from extended systematic evaluation and inquiry. Residents were asked to score their responses to statements on a five-point Likert scale (strongly disagree to strongly agree). For analysis, we dichotomized responses to each survey question to agree (score of 4 or 5), or not agree (1 through 3).
Therefore, we determined that an assessment of residents' opinions of our course and the case formats presented could serve as a beginning for such inquiry. We therefore chose to focus on resident perceptions in three key areas: Do the case discussions cover practical issues that the residents believe they do/will face in clinical practice? Are the case discussions broad enough to cover the wide array of ethical issue they do/will face? And which case format in general do they prefer, which format do they believe facilitates their own learning, and ideally what mix of formats would they prefer? These specific areas were chosen because our education team believed that the differences in case formats would most likely impact these areas. The purpose of this paper is to describe our curriculum and report the findings of our resident survey. These findings may assist other residency programs as they develop ethics and professionalism curricula.
Residents were nearly evenly split between preferring IGC, RGC, or both equally and were split in which they believed best facilitated their learning. In general, however, residents felt that a mix of both formats was ideal regardless of which format they personally preferred (Fig 1). Responses to questions regarding how practical residents found sessions and the breadth of cases covered are presented in Figures 2 and 3. When asked what percentage of cases would ideally be IGCs and RGCs, on average, residents wanted 51% of cases to be resident-generated, and 49% to be instructorgenerated.
Based on our relatively small sample at a single institution, we believe that educators should consider incorporating both instructor-generated and resident-generated cases in their ethics and professionalism curricula, and should evaluate the utility of such a model at their own institution.
Ethics and professionalism in the pediatric Our findings support the view that philosophy and sociology should be included in medical school and specialty training curricula. Curricula should be reframed to introduce students to habits of thought that recognize the need for critical reflection on the social processes in which they are embedded, and on the philosophical assumptions that underpin their practice. Forty-two anesthesiology trainees participated in a 2-part exercise with mixed-realism simulation. The first part took place using a mannequin patient in a simulated operating room where trainees became enmeshed in a clinical episode that led to an adverse event and the second part in a simulated postoperative care unit where the learner is asked to disclose to a standardized patient who systematically moves through epochs of grief response. Two raters scored subjects using an assessment instrument we developed that combines a 4element behaviorally anchored rating scale (BARS) and a 5stage objective rating scale.
Thus, the purposes of this study were to (1) demonstrate the feasibility of a structured technique for teaching adverse event disclosure using mixed-realism simulation, (2) develop and begin to validate an instrument for assessing performance, and (3) describe the disclosure practice of a representative cohort of anesthesiology trainees.
The performance scores for elements within the BARS and the 5-stage instrument showed excellent interrater reliability, appropriate range and high internal consistency.
In future work, we can test the learning in subsequent mixedrealism cases to assess learning as compared with groups having other forms of disclosure education. Furthermore, studies of the effectiveness of the learning in a naturalistic environment are possible.

Ethics-in-Oncology
Forums.

Mehta et al. 2007
Qualitative NA 14 We developed an ethics curriculum for hematology/oncology fellows who had already learned medical ethics from medical school and residency programs. The goal of the ethics program was to train fellows in ethics issues specific to hematology/oncology; to raise awareness of ethical issues; and to teach fellows to write, edit, and publish reviews in specific ethical issues Fellows learned to summarize expert opinions, to understand diversity in cultural concepts relating to ethics, and to crystallize their approaches to ethical dilemmas to selected oncology patients. Fellows were also trained to write ethics discussions in manuscript format, edit the manuscripts, and submit them for publication.
Presentations -Most of the issues related to miscommunications between patient, family, and physicians. Many related to disagreements in treatment, communications in prognosis, or resource allocation. Deliberations -Faculty included hematologists-oncologists, palliative care experts, ethicists, peers, nurses, students, and ethics committee members. Attendance by all the Fellows was required. All of the discussions entailed lively debates among faculty with opposing opinions. One faculty was assigned to facilitate discussions so that that the flow of the discussion could continue despite disagreements. Manuscripts -Of the cases, 12 were written and edited for publication; of these, 6 were published, 1 is in press, 3 were submitted, and 2 are in preparation. Many others were started but not completed.
Reasons for noncompletion relate primarily to the fellow losing interest as they progress in the program or after they leave the program or for other Methods that included readings with discussions appeared to be more beneficial than those in which read-ing material alone was reviewed.23 Some methods are innovative but may not be easy to duplicate at all centers. These included dramatic representations of medical moral dilemmas, film festivals with medical moral dilemmas embedded into the content,15 debates, or games such as "scruples." Fellows are required to integrate the experience through reviewing it in different phases. Thus, the steps of (a) detecting and selecting the ethical dilemma to present, (b Descriptive NA NA Our program was designed to overcome the following obstacles: (1) time constraints of faculty and residents, (2) scheduling difficulties and lack of continuity, (3) attitudes of residents toward the material, and (4) inadequate ethics training among faculty. In addition to traditional topics in medical ethics, the curriculum focuses on issues that confront residents primarily during their training, issues that may shape their professional values in important ways.
To describe the successful implementation of a structured ethics curriculum for pediatric residents.
This ethics curriculum has been successfully implemented in our own program and offers solutions to common barriers faced by those seeking to implement an ethics curriculum for pediatric residents.
We present the ethics curriculum currently in use at our institution as a tool that may be adopted as it stands or as altered by others as they develop their own program's ethics curriculum. We believe the pro-posed curriculum directly confronts many of the barriers to successful ethics education of pediatric residents. We conducted an e-mail survey to learn how radiology residency programs responded to the mandate to include the teaching of ethics. Our purpose was twofold: to get a sense of the current state of ethics education in radiology residency programs and to learn possible effective strategies that might be suitable for use in our program to enhance our own curriculum.
With the rapid and continuous introduction of new technologies and techniques in diagnostic and interventional radiology, the radiology resident must master an ever-expanding knowledge base during the 4-year residency program. The resident is expected to develop a level of competence, resulting in board certification. However, successful medical practice also depends on competency in nonmedical areas such as costcontainment, medical-legal issues, business acumen, effective communication, professionalism, and ethics.
Radiology residency programs have responded to the ACGME mandate to incorporate the teaching of ethics in a variety of ways. However, a survey that we conducted indicated that 38% of programs still offer no teaching of ethics to their radiology residents. The ACR videotape about ethics is used by many programs that do incorporate ethics in the curriculum.
On the basis of the enthusiastic discussions at the sessions, the personal viewpoints offered, and the opportunity for residents to listen to the diversity of staff opinions regarding ethics issues, we believe that we achieved our goal of increasing the ethics component of our radiology residency program. Although our method of incorporating ethics teaching into our residency program may not be suitable for other programs, it may serve as a model on which others can expand. ethics among faculty and postgraduates. This was done using a retro pre-questionnaire. We performed a Kolmogorov Smirnov test to measure the normality, Mann Whitney U-test to test the difference in scores between faculty and postgraduates and a Wilcoxin signed rank test to measure the prepost scores.
provides a concrete measure of the effectiveness of the program. This helps in policy making and also for taking corrective actions in future if found necessary.
in research ethics could be effective.
A randomized trial of teaching bioethics to surgical residents Robb et al. 2004 Quantitative 17 NA We randomized 31 first-and second-year surgical residents to either a SP-based seminar or a traditional seminar on informed consent. Immediately after the seminars, we evaluated resident performance in patient encounters on informed consent by using an objective structured clinical examination. Their knowledge of informed consent was also evaluated by using a 20-question shortanswer written examination immediately after the seminars and then 3 weeks later.
Our objective was to evaluate the effectiveness of a SP-based seminar compared with a traditional seminar for teaching informed consent to surgical residents. We chose this topic because it is an essential skill for surgeons, and we targeted firstand second-year surgical residents because their clinical responsibilities include ensuring that informed consent is obtained for surgical procedures. Our primary outcome was resident performance in an objective structured clinical examination. Our secondary outcome was resident knowledge using a 20question short-answer written examination. We briefly explore the current published data on ethics education in pediatric residency and neonatal-perinatal medicine fellowship programs. Then, we discuss the questions an academic educator may face while developing an ethics curriculum in his/her medical institution. Finally, we present the ethics curriculum that we developed in our neonatalperinatal medicine fellowship program.
Neonatology is one of the specialties that has immensely benefited from advances in medical technology in the last few decades. These advances have paralleled the rise of the civil rights movements and wider recognition of individual rights. As a result, ethical decision-making has become more complex, involving patients, parents, members of the health care team, and society in general. This has created a need for formal ethics education in neonatalperinatal medicine fellowship programs.
Neonatology is one of the specialties that has immensely benefited from advances in medical technology. Infants who previously could not survive for medical and surgical reasons now survive. These children sometimes survive with many problems causing parents and patients, physicians and healthcare providers, and society to question the quality of the life saved; even feeling that they are held hostage by technology.43 Physicians spend long hours with parents who request "futile" treatments for their infants, while the physician feels the parent is not acting in the best interest of the infant. The moral dilemmas that neonatologists address in their daily practice are ever increasing.
it becomes essential for the neonatal-perinatal medicine fellowship programs to educate fellows so that they will have the ability to approach ethical dilemmas systematically; a skill that must be learned and cultivated over time.40 This will only improve the most effective paradigm for decision-making in medicine; the shared decision-making model. We propose a curriculum for postgraduate year 3 or 4 residents and fellows that consists of 12 monthly 90-minute seminars. During each session a senior trainee will present a case from a specific clinical setting or sub-specialism of psychiatry that focuses on one or two core ethical or professionalism principles. The trainee will use Roberts' six-step algorithm as a framework for the case presentation (Roberts et al., 1996). That senior trainee will also be responsible for inviting one or two faculty discussants who supervised the care of the particular patient or who is an expert in the relevant psychiatric specialism. We developed and instituted a case-based didactic program in clinical medical ethics for internal medicine residents with the following course objectives: (1) to increase understanding of the theoretical, legal, and practical components of clinical ethics; (2) to apply these lessons to the inherent ethical challenges faced in clinical practice.
To develop and evaluate an experiential educational program for physicians.
Residents unanimously agreed or strongly agreed that (1) medical ethics is a valuable component of medical education, We sought to determine whether residents could obtain content understanding and retention when the material was presented as an online, independent-learning module. If successful, we anticipated that these resources would supplement and enhance our professionalism curriculum.
Cohort I demonstrated improvement in 3-month Post module assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing.
This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.