November - December 1999

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note:This column is the first of a two-part series on ethical issues and precepting. Jessica Pierce, PhD, is an ethicist, and Audrey Paulman, MD, is a practicing family physician and preceptor, at the University of Nebraska in Omaha.
I welcome your comments about this feature, and I also encourage all predoctoral directors to make copies of this feature in its entirety and distribute it to their preceptors. Send your submissions to Paul Paulman, MD, University of Nebraska, Department of Family Medicine, 600 South 42nd Street, Box 983075, 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.

Almost all medical schools now offer some formal ethics curriculum to medical students in their first 2 years. Preceptors play a key role in this ethics education. For schools that incorporate precepting into these first years, the brief clinical exposure offers an important resource for the ethics faculty. Since ethics tends to be abstract, the real-life exposure can provide case examples and key material for discussion.

There are many other ways in which the precepting situation involves ethics education. In particular, there are important shortcomings in the student’s ethics education that the preceptor can help correct.

1) Mentoring Ethical Behavior
The preceptor plays a key role in mentoring ethical behavior. First, the preceptor models ethical behavior in the practice of medicine. If a student is exposed to fraudulent billing practices or to subtle forms of discrimination against patients of lower socioeconomic class, this will strongly influence what the student considers to be appropriate and acceptable standards of professional behavior. Preceptors must hold themselves to a high standard.

Second, the preceptor models ethical behavior in his or her relations with students. Preceptors should provide a nourishing learning environment and give appropriate feedback in a tactful, private manner, so that students learn respectful behaviors in professional interactions.

The preceptor should also be aware that there is a potential tension between what might be labeled the “formal” and “shadow” curricula in medical school. The formal curriculum is what happens in the ethics class. Typically, students will learn the basic ethical requirements of confidentiality, informed consent, telling the truth, and respect for patient beliefs. Students may also have a chance to discuss difficult cases, such as limiting care of the dying patient.

The perceptive student, however, will notice a tension between the formal curriculum and the so-called shadow curriculum or what gets taught incidentally through observation and role modeling. Many times, actual practices fall somewhat short of the ethical ideals taught in class. For example, students may learn that absolutely all patient information is confidential and must be protected. However, on rounds in the hospital, charts will be laying open on tables, conversations about patients will be going on in the hallways, and so on. Students are much more likely to learn through this shadow curriculum, through real medicine, than through an abstract ethics lecture. Dealing openly with these discrepancies—even if this means pointing out shortcomings in day-to-day medicine—will help students develop a clearer sense of appropriate behavior.

2) Addressing Student-specific Issues
The student will face issues particular to his or her role as student that are rarely covered in formal ethics curricula. Ethical issues unique to the learning role include, for example, the tension between practicing on patients and not harming patients and the question of how a student should introduce himself or herself to patients. The preceptor can help students tremendously by being aware of these student-specific issues and watching for a teaching moment to open discussion.

3) Teaching a Process for Ethical Decision Making
The preceptor is teaching students, especially through role modeling, how to make good decisions. In addition to clinical problem solving, students need to learn a process for identifying and working through ethical problems. Students need to learn not only how to recognize an ethical problem but how to engage both internal and external resources toward resolving the problem. This is not an innate talent called being ethical; it is a learned skill, which involves self-reflectiveness, broad-mindedness, sensitivity, and tact. The preceptor teaches this by modeling, of course, but also by talking through the steps of ethical decision making. One of the key teaching elements in precepting situations is ethics. The pearl of ethics teaching in medicine is respect for the patient as a person. Inevitably, the preceptor models a set of behaviors and attitudes toward patients in the daily clinical setting. Even if a preceptor believes he or she is sticking purely to medicine, some ethics teaching inevitably takes place through the mentoring process.

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.

Preceptor Basic Book List