Editor’s Note: This column is the second of a two-part series on ethical issues and precepting. (The first part was published in the November-December 1999 issue of Family Medicine). Audrey Paulman, MD, is a practicing physician and preceptor, and Jessica Pierce, PhD, is an ethicist, both at the University of Nebraska Medical Center.

I welcome your comments about this feature, which is also published on the STFM Web site at www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@unmc.edu. Submissions should be no longer than 3–4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

The Physician as Ethics Educator

Audrey Paulman, MD; Jessica Pierce, PhD
(Fam Med 2000;32(6):381-2.)

Students will probably have contact with a community preceptor concurrent with some formal ethics curriculum required during the first 2 years of medical school. While formal education offers the basics of ethics, it is the experience with the community preceptor that allows students to develop their own style and sense of moral center. Preceptors can help students accept responsibility when making difficult choices and model effective resolution of ethical problems.

The formal ethics curriculum typically covers such issues as end-of-life decisions, informed consent, confidentiality, abortion, and the constraints of managed care. While these topics are important, the student may still not learn the most important ethics skills: an aptitude for moral discernment and an effective process for ethical decision making. These skills are learned through mentoring and through the practice of caring for patients, both of which occur in the preceptor’s office.

Unfortunately, the structure of the precepting situation does not encourage the student to engage in active ethical problem solving. Instead, the student will likely be in the role of passive observer while the physician deals with patients, family members, insurance carriers, institutions, and coworkers. Community preceptors, with exposure to medical students early in their training, have a unique opportunity to help students develop ethical skills that will have lifelong impact.

It is in the community preceptor’s office that the student will first be exposed to the basics of ethical care. The student needs to witness a confidential and respectful relationship with the patient and observe care that is in the best interest of the patient and those persons surrounding the patient. The student idealistically follows the Hippocratic Oath of “first do no harm.” Yet, so many issues of medicine seem to involve pathways that may benefit some parties while harming others. The preceptor can help the student identify these conflicts and plan the most appropriate course of action.

There are many ways to help the student identify an ethical problem. Internally, the student may feel a sense of uneasiness or conflict. Externally, the student may be exposed to family unrest and conflict, attorneys, police, television and news media, or even pickets. Each should help the student identify the problem.

The student then needs to learn to define the problem, which will involve identifying what values are at stake for those involved. To complete this task, the student should initially reflect on this problem to identify existing feelings and biases. Then, those involved should be interviewed to identify issues. Those individuals involved typically include the patient, the family, the caregivers in the hospital, the long-term caregivers at home, the financially responsible party, and the institution providing care.

The student needs to identify what values are at stake for each of those affected by the issue. Some of the values frequently at stake in ethical questions are sanctity of life, fairness, religious beliefs, and monetary impact. Each of those involved may feel that a different value is at stake or may value the same thing in quite diverse ways.

All identified possible courses of action or resolutions need to be considered. With any solution, there will be positive and negative impacts on each of the parties involved. The best option is then chosen for the course of action. In medicine, when treating illness is the issue, the option with the least-negative impact is usually the correct course of action. It is difficult for the student to realize that in treating illness, nothing is without cost in medicine; nothing is without risk of complication, pain, scarring, time, or expense.

In practice, the preceptor should be alert to clues that identify a student facing an ethical challenge. Statements like, “I don’t want to hurt the patient” or “I don’t feel right” are natural openings for the preceptor to begin a discussion. For example, a student may express concern about practicing an IV on the patient. This is an ideal opportunity to formally help the student identify the issues involved and the values at stake. For the student, the procedure needs to be learned, but there is a risk of exposure to contagious disease or injury from a combative patient. The patient must also be told that the person performing the procedure is a student, even though the student may risk refusal by the patient. For the patient, the IV needs to be started. While patients should be spared unnecessary pain from repeated needle sticks, many patient feel happy that they can help young physicians in training. For the institution and the financially responsible party, there needs to be cost-effective use of supplies and an acceptable complication rate. The student can identify the issue, assess what values are at stake, and choose the appropriate course of action in this case. The student may then validate this decision with the preceptor.

Doctors in training need an opportunity to consciously and reflectively develop their moral sensibility since this is a key component of their clinical skills. The preceptor can make a valuable contribution to a medical student’s training by providing a safe and encouraging place for the student to practice identifying and working through real ethical problems.

Corresponding Author: Address correspondence to Dr Pierce, University of Nebraska Medical Center, Department of Preventive and Societal Medicine, 984350 Nebraska Medical Center, Omaha, NE 68198-4350. 402-559-4325. Fax: 402-559-7259. E-mail: jpierce@unmc.edu.