Meeting the challenge of teaching bioethics: a successful residency curricula utilizing Team-Based Learning

Figures & data

Figure 1. The team based learning process [21]. iRAT: Individual Readiness Assurance Test: a brief multiple-choice quiz to assess learners on knowledge necessary to achieve learning outcomes; gRAT: Group Readiness Assurance Test: the iRAT test is taken collaboratively within a small group, with immediate feedback given as to the correct answer once a group commits by consensus; a discussion of learning points follows, facilitated by faculty; TApp: Team Application Exercise: small groups of learners work through an ethical case/common problem together and arrive at an answer by consensus; each group reveals its answer simultaneously; faculty facilitate inter-group discussion surrounding ethical points of conflict.

Figure 2. A TBL bioethics “Deliverable”: The four-box method of ethical analysis.

Table 1. TBL bioethics sessions, content areas, and team application exercises.

TBL bioethics sessions	Examples of content assessed in iRAT/gRAT	Examples of multi-format TApp exercises
1. Introduction to Medical Ethics and the Four Box Method	Principles of bioethics such as autonomy, beneficence, nonmaleficence, justice; differences between adult and paediatric bioethics; Jonsen et. al’s “Four Box Method”	Published ethical case regarding a teenager’s wish to forgo chemotherapy for a treatable cancer against the advice of the medical team; Use of Four Box Method
2. Assent and Consent	Differences between assent and consent and clinical applications	Ethical case of new teenage mother with surrogate decision-making power in the neonatal intensive care unit
3. Professionalism and Social Media	Professionalism definitions; professional obligations to parents, families, and patients within social media; behaviour outside of work on social media	Several simulated Facebook profiles were created and learners were asked to critique them and discuss obligations of providers
4. Neonatal and Perinatal Ethics	End of life decision making in an infant with limited lifespan/Trisomy 13	Use of video/YouTube case of “Baby Thomas” and the Four Box Method: http://www.youtube.com/watch?v=ToNWquoXqJI. .
5. Spirituality in Medicine	Navigating conflicts between spiritual beliefs of providers and patients and medical outcomes	Discussion of real case at our institution of a devoutly Hindu family whose spiritual beliefs come into conflict with the advice of the medical team; learners form their own “Ethics Committee” and must come to a consensus decision using the Four Box Method
6. Paediatric Palliative Care	The ethical importance of palliative care; the nature of suffering; Palliative vs Hospice Care	Role play: Learners engage in a series of difficult conversations with an “SP” (“simulated parent”) of a seriously ill child; expert clinical faculty in paediatric palliative care participate in role play and discussion
7. Interpersonal Relationships	Professionalism; the role of hierarchy in the life of a resident; integrity	A clinical case of a resident learner who must respond to a clinical decision by an attending physician on the inpatient service they believe is wrong; learners role play “scripts” of how they would communicate and the ethical implications of those responses.
8. Paediatric Decision Making and the Best Interest Standard	Conflicts between parents and physicians/healthcare team; use and controversies surrounding the “best interest standard” in paediatrics	Learners analyse the famous recent bioethics case of “Charlie Gard.” They use the Four Box Method, are divided into teams, and then a friendly mock debate is conducted with brief speeches, cross examinations, and rebuttal periods.
9. Child Abuse, Intimate Partner Violence, and Toxic Stress	Impact of intimate partner violence on the developing child; ethical and social issues underlying family violence and the impact on health; legal and moral obligations of paediatricians to prevent family violence	Resident learners work through three ethical cases in large and small group settings: (1) a case of intimate partner violence with attention to cultural stigma and practices; (2) a publicly available video case of a female survivor of domestic violence and the effect on her children; (3) learners listen to a graphic phone call of a child calling 911 while violence is occurring in the home
10. Paediatric Research Ethics	The importance and dignity of the subject in research; the ethical obligations of the physician-researcher; The Belmont Report and Nuremberg Principles; the purpose of the IRB	Learners work in groups through a simulated IRB application and discuss problems and solutions, facilitated by expert faculty

Table 2. Individual results of Assurance Tests by trainee year.

	Total Attended (PGY 1-4)	PGY1		PGY2		PGY3		PGY4
		iRAT	gRAT	iRAT	gRAT	iRAT	gRAT	iRAT	gRAT
N		122	134	115	120	75	74	13	9
TBL 1. Introduction to Medical Ethics and the Four Box Method	34	70% (13/13)	96% (13/13)	70% (11/11)	96% (11/11)	70% (9/9)	93% (9/9)	50% (1/1)	85% (1/1)
TBL 2. Assent and Consent	35	53% (15/16)	74% (15/16)	64% (9/9)	69% (8/9)	64% (10/10)	71% (10/10)	–	–
TBL 3. Professionalism and Social Media	26	68% (9/12)	92% (12/12)	67% (8/9)	90% (9/9)	56% (4/5)	86% (5/5)	–	–
TBL 4. NICU and Early Life	43	71% (15/21)	86% (21/21)	69% (11/13)	84% (13/13)	69% (6/8)	93% (8/8)	88% (1/1)	88% (1/1)
TBL 5. Spirituality in Medicine	24	89% (9/10)	94% (10/10)	75% (12/13)	89% (13/13)	63% (1/1)	94% (1/1)	–	–
TBL 6. Palliative Care	44	72% (44/44)	82% (44/44)	–	–	–	–	–	–
TBL 7. Interpersonal Relationships	30	82% (17/19)	95% (19/19)	86% (7/8)	95% (8/8)	81% (2/2)	100% (2/2)	75% (1/1)	88% (1/1)
TBL 8. Decision Making and the Best Interest Standard	40	–	–	–	–	79% (31/31)	95% (26/31)	74% (9/9)	100% (5/9)
TBL 9. Child Abuse, Inter-Partner Violence, and Toxic Stress	44	–	–	72% (44/44)	96% (44/44)			–	–
TBL 10. Research Ethics	28	–	–	79% (13/14)	88% (14/14)	78% (12/13)	89% (13/13)	63% (1/1)	81% (1/1)
Total		72%	87%	72%	90%	73%	90%	72%	93%

TBL: Team Based Learning; iRAT: Individual Readiness Assurance Test; gRAT: Group Readiness Assurance Test; PGY: Post-Graduate Year.

Table 3. Comparison of average group readiness assurance test scores by trainee year.

	PGY1	PGY2	PGY3
PGY2	0.0001
PGY3	0.0079	0.1979
PGY4	0.0264	0.2891	0.1841

gRAT: Group Readiness Assurance Test; PGY: Post-Graduate Year.

Parmelee D, Michaelsen LK, Cook S, et al. Team-based learning: a practical guide: AMEE guide no. 65. Med Teach. 2012;34(5):e275–e287.

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Data availability statement

The data that support the findings of this study are available from the corresponding author, Dr. Fernandes, upon reasonable request.