The evolution of integration: Innovations in clinical skills and ethics in first year medicine

Abstract

Critical self-reflection, medical ethics and clinical skills are each important components of medical education but are seldom linked in curriculum development. We developed a curriculum that builds on the existing integration of ethics education into the clinical skills course to more explicitly link these three skills. The curriculum builds on the existing integration of clinical skills and ethics in first year medicine. It refines the integration through scheduling changes; adds case studies that emphasise the social, economic and political context of our province's patient population; and introduces reflection on the “culture of medicine” as a way to have students articulate and understand their own values and moral decision making frameworks. This structured Clinical Skills course is a model for successfully integrating critical self-reflection, reflection on the political, economic and cultural contexts shaping health and healthcare, and moral decision making into clinical skills training.

Notes

Notes

1. Later itemized as respect, paying attention to the patient, being personally present, having a caring intent, and flexibility (Coutts & Rogers 2000).

2. Attendance was made mandatory for the ethics sessions just as it had always been for the clinical stream. This expectation is framed as the beginning of their role as professionals with their obligation to classmates, teachers and eventually patients. We equate missing a session to missing a clinical obligation.

3. Determinants of health are already taught through the broader undergraduate medicine Community Health course and are a helpful background for the students to discuss poverty and its impact on health and health care delivery.

4. The patient scenarios are standardized.

5. The first of these is a formative assignment in the area of history of medicine, part of the broader humanities teaching within clinical skills.

6. This 20% includes history of medicine teaching within the broader humanities component of Clinical Skills in Med 1; history constitutes approximately one-fifth of the humanities teaching, with the remainder being the ethics/law teaching.

7. Students attend three-hour sessions, weekly for 24 weeks, in the first year of medical school Clinical Skills Course. They are divided in to groups of 7 or 8 and maintain the same group throughout the course. They have the same co-facilitators, a physician and community social worker, for the year. This significantly contributes to continuity of teaching and allows for more “safety” within each group. The format of the course uses the doctor-patient encounter as the template for the learning process. We use “Patient-Centered Medicine, Transforming the Clinical Method” as the basis for the style of interviewing taught. Twenty-four hours of class time in ethics, history of medicine, and health law are held throughout the CS1 course, with a format of full-group discussion and debate. Content covers the full range of ethical, legal, and social (historical, cultural) topics set out by the CMA's Objectives of the Considerations of the Legal, Ethical and Organizational Aspects of the Practice of Medicine (CLEO) and the American Association of Medical College's Medical School Objectives Project (MSOP) (Cohen, 2006).

8. In the ethics component, we frame our discussions using the “narrative structuring” approach, detailed elsewhere (Pullman et al., 2005). Students are taught how to reflect on patient narratives and to have a better understanding of their own narrative and how it influences their development as future physicians. Teaching strategies include role-play, debate on contentious (morally salient) issues, reference to popular television shows and films, and journaling. Invited guests present alternative (non-medical) ways of understanding illness and healing (e.g., film makers, writers, artists, anti-poverty activists).