 Which is going to be about ethics education and I am very pleased to announce that our first speaker is Dr. Lori Lacombe, who is the Sydney G. Page Jr. Professor of Bioethics and Humanities, Professor of Heman Compalative Care and Director of the Hospice and Palliative Medicine Fellowship at Virginia Commonwealth University, from which she retired on Friday and on Monday will be starting work at the University of Iowa. So I guess her husband is moving the family and she'll take a plane to the other side of the country. Her research and clinical focus has always been on provision of cancer and palliative care for marginalized populations. In her past, Dr. Lacombe completed both her medical degree in residency training at Creighton University. Lori, welcome back to Chicago and to the Midwest. Good morning everybody. Um My topic is Medical Ethics Education and I've just been every year been dying to come back and talk about medical ethics education And I learned so much about it When I was here and I got to be one of the educators in one of the small group leaders and that was Wonderful and I took that back with me when I went to VCU to start the ethics program there but I I Sometimes feel that even after 20 years or so of doing this. I I'm not really sure what I'm doing And so I I know hopefully many of you got the survey that I sent out And thank you so much for completing it and sending it back because I still feel like We need to talk more about it and have more dialogue because I still don't know that See I have to figure out how to do this that after 20 years and 10 years later after this sort of seminal article was written in the academic in academic medicine Where Eccles and others said the time has come to organize an effort to improve and validate medical ethics education Did this big survey of deans of medical schools across the country and found out that everybody was teaching it in every Different way and teaching all kinds of different things and evaluating in different ways that there really wasn't any one sort of common theme and So I thought well, let me send out a survey to People who I know are at the cutting edge and just really doing Wonderful things with teaching ethics and it really hadn't changed very much and I'm going to present those Results today, and I'm hoping that I can get through this fairly quickly because I learned so much when I come here once a year and listen to the questions and answers and also I'm able to have lunch and and network with people and find out what they're doing and I take always take great ideas back With me and hopefully many of you do too. So that's what I'm here to do So the nice thing is that both the LCME that accredits Medical schools and the ACG me both require some sort of ethics education and that really gives us at least some Something to say to the deans and to the and to the directors who often think that it's fluff and Offens don't give us very much time in the curriculum and I always come back to them and say look at this part of the LCME a Medical school must teach medical ethics and human values and require its students to exhibit Scrupulous ethical principles in caring for patients and in relating to patients families and to others involved in patient care Each school should assure that students receive instruction in appropriate medical ethics human values and Communication skills before engaging in patient care activities as students take on increasingly I think that got deleted. I'm sorry about that In student patient interactions, there should be a means for identifying possible breaches of ethics and patient care Either through faculty resident observation of the encounter patient reporting or some other appropriate method which tells Me that part that it shouldn't just be one or two ethics Educators, but it should be the whole faculty that is educated to some degree in clinical medical ethics The ACG me is less specific But it's really great to go through the common program requirements for almost any of the residency programs Including pathology and radiology and find that they require ethics education, but it's not very specific And in the new milestones project Where they're evaluating resident competency a very different way in a better way in a more specific way There are multiple ethics based competencies and you could really say as you go through it that Ethics is the underpinning of everything that people do in clinical medicine And they do actually even have one of the milestones that is exhibits integrity and ethical behavior in professional conduct So there are There are some Sort of there's backing for us to be teaching ethics in both the undergrad and the graduate medical education So some of the questions that I have and I've been thinking about for years And I ask people when I meet people that are teaching are should there be a core curriculum that everyone teaches Should there be a certain amount of time required should evaluations be uniform? What about teaching methods? How do we measure outcomes? How do we even know that teaching ethics works? I Sort of scoured the literature for anything that would tell me whether it works or not and it's really hard to find What matters and I think one of the One of the presentations is going to address some of this is it virtue or is it skills? Can virtue be learned? Can the virtuous physician be developed? And so these are the these are the questions that I asked of The attendance here and thank you so much because I couldn't believe it. I've got almost a hundred responses That was amazing So first one was are you involved in ethics education? About 35 said no and sixty five said yes And these are the ways that they said they teach ethics Flipped classroom was is sort of a newer concept But people are using it so that they can get more time in the classroom with pay with the students video vignettes Case discussions. I think happily it won out as the top Method for education plenary discussions small group work We're still doing a lot of lecturing and I'm not sure that that's the best way to teach ethics But I think when it's accompanied by case discussions and other things it seems to work and then Reflection came out as being one of the top methods for Education so that was really exciting and then for Evaluation of the medical students the MCQ exam Not a lot of people use that although I'm finding that there are some skills and some knowledge Pieces of knowledge that are very testable things about advanced directives Parts about decision-making capacity other things that are very knowledge Based that I think you really can use for MCQ exam and when we have 245 medical students in our Medical school at VCU and it's really hard to grade more than you know 40 40 or so Essays or reflections so sometimes MCQs have to work But a lot of people use essays for evaluation reflection Pure assessment self-assessment and then other things Now the most important of course were the qualitative questions So the first one was what are the challenges or boundaries that you see and I'm just gonna Sort of aggregate them first and say one of the biggest one was time Time both for the instructors to teach and to grade and evaluate and for the students and residents Finding time in their curricula and in their in the residents, especially their busy lives Getting them interested Recruiting small group leaders so interest in both the the teachers and the small group Facilitators and then interest from the residents and students Funding is a really tough one For teachers coordinators programs and standardized patients in as many places are moving to more of an RVU based type of reimbursement for especially for physicians. I think They're finding Less and less time to become small group facilitators where they don't see that their time is valued and then lack of faculty expertise Like of clinical experience to contextualize medical ethics lessons a couple people said, you know It's really hard for students to To really understand what I'm talking about when they're in their first and second year before they start the clinics lack of interest and even pushback by program director Having no right answers one person wrote or having solutions to problems that seem difficult to obtain and Making reflection not feel like forced reflection Plagiarism was one and no consequences if it is discovered one person said lack of integrity among administrators when students cheat Another person said the need for clinicians involved in the educational process to be relieved from Responsibility to think about ethics because of time pressure and wanting the bioethicists to just do it and give them a solution Also the mistaking of ethics consultation for a legal protection rather than educational opportunity And one person said none everything works perfectly as if we were in heaven Contenders I could think of for that answer If you had unlimited time and resources, how would you change your course and again? The aggregates are more case-based discussions people found that they really thought that the case-based Small group discussions were the richest and the best way that students could learn More communication skills with standardized patients more patient panels more standardized patients Very difficult to fund standardized patients. They're really expensive essay based or verbal argument evaluations to meet more often more time to show movie clips and discuss books One person said maybe have a little cam follow me around which could blur faces and erase identities And yet allow the context to be seen and heard Ethics consultation would meet like morning report with debriefing and de-stressing of staff and or families after issues arise But have not escalated Fostered doctor care amongst the physicians to lessen guilt and burnout One person said I would redo it in fourth-year medical school and then have the students compare and contrast how they're thinking evolved with experience And we've actually done that and that's been a really neat process for the fourth years to sort of come back and teach and Talk about some cases that they had been presented with in their first year and then come back and talk and say boy This looks really different to me now Another person said would train more faculty in residence in principles of ethics and have them help teach the ethics curriculum to residents and medical students So lots of faculty development in ethics and that seems like that That really works and then it gets everybody energized It would be nice to create a critical mass of knowledgeable ethics educators that will help design and carry out an ethics curriculum and That one person again said I would get everyone a million dollars So Again, my questions are about the cork recurriculum should there be a certain amount of time required Should evaluations be a uniform teaching methods? How do we measure outcomes? What matters? Does anything matter? Is it virtue or is it skills or is it both or neither? Can virtue be learned and can we really develop virtuous? Physicians, so I'd like to turn the lights up and Bring people to the Microphones and hear what you have to say Hi, September Hi, Lori Lori and I went to medical school together most people don't realize that I am a product of Crayton University in Omaha, Nebraska where we did have a lot of a lot of sort of focus on Ethical issues as we were coming up and Lori by now figured I would probably be Novelist which I am and not a doctor any longer, but definitely a filmmaker Here's the thing is that I feel very strongly that some of the guidelines that have been developed around What a bioethicist is and what the attributes of a bioethicist are? Should be the focus of what we try to do with with students and with people when we're training The issue is to not focus just on the case but to focus on how they can learn to facilitate cases and Facilitate certain and to develop the attributes while they're in training and not to suppress their natural Instincts I sort of think about the priests who used to come into our anatomy lab Because that's where we were then we would run on the track and we would so it was integrated into Who we were that we would begin to ask questions? the mistake that I'm finding is I did provide that comment about I'm mistaken for a legal stamp, right or Or people just want to do it the big problem that I'm having is getting people to understand that everybody Needs to be a bioethicist So that is not we've fallen into the subspecialty issue right so we need for everybody to think that within them as The man who broke the US Public Health Service syphilis study said it's in the main. It is within each of us to know It is within each of us to know It's not something that you send to a specialty to do and the value that I'm finding as missing is that when I do an ethics consult the person who's actually managing that patient is Losing the ability to interact With that patient on those issues and the cache that you get from doing that with the family and over time And over multiple admissions and is what they're missing. So I would Have you done any like tracking over time? like when medical students are Students where they have a case where they see it over and over again like the guy that got hit by a tractor when we were in First year and I saw him For two years and four different services to kind of track those issues pick a patient and see how often that's a great idea Does anybody do that? So that's a though. So that's my thing. I'd like to see people tracking Over the years there in medical school Hi Maggie. Thank you September Hey, Lori. Thank you for that. I I'm at Hopkins and I spend a huge amount of my time teaching ethics throughout the hospital So I have this really cool job. I get to teach ethics to the surgery residents the Peds residents the medicine residents OBGYN neurology Adolescent psych. I mean we just it's a really Hopkins has really embraced the notion of ethics education Even with some funding But I think even though I have me now It's really we get to do some pretty incredible stuff But I one of the questions that will always come back is can you show that ethics education works? Exactly, and I think that that's a really big deal except that maybe the answer is no And we should stop trying to show that it works because in the short term is very difficult We could also say have a different sort of approach and say here are the goals of ethics education It's to make sure that everybody knows how to recognize an ethics issue and that everybody has some sort of beginning ability to discuss it Because I think that trying to if we hang our hats on showing that ethics education works to change behavior or to change patient outcomes We can get little bits of answers here and there, but it strikes me that might be entirely the wrong question So I think that I want to I want to present that and sort of see if we can maybe have a better conversation About what are the goals of ethics education? I mean what we think they ought to be and then the final point is that I think one of the things that we have done wrong for a very long time is we We sort of subject students to ethics education without looking first to see what their actual needs are So as nice as we all are a whole lot of ethics education remains very much teacher-centered I'm gonna tell you what I think you ought to know instead of going and the times that I've had a chance to do this Actually do some observational work to see what the ethics questions faced by the residents in the clinics are It ends up offering and creating a very different curriculum Than sort of the standard big-ticket item curriculums that we tend to teach So I think there's a couple sort of very basic pedagogical tools that we need and one of them is a careful clear-headed Evidence-based needs assessment We keep trying to fly by that and just teach the things that we're most interested in or the things that we see They may not be the things that our students need from us so I think we need to get a little bit more real about ethics education and Sort of humble ourselves to actually look at it from the point of view of the learner as opposed to the teacher That's great. Thank you No before you step down I'm going to steal this and ask one question of you as well Which is you know your point about getting more faculty and more even residents involved in the teaching How do you plan to structure that type of curriculum? Is it just going to be in a sense 202 versus ethics 101 or I mean I think it's a really important question. How do we train the trainers type of thing? Besides making them go through an entire year-long ethics program exactly Did you want to offer that? Sure Karen Devon University of Toronto, so I Just got some funding in Toronto to take a concept that actually I witnessed here through Peter and the surgical group Which is called ethics M&Ms Where we discussed an ethics case once a month at a regular M&Ms rounds and so when I got to Toronto I started doing that with the residents at my Institution there's 11 teaching hospitals that make up the system and what I do is I actually created a template and have the residents work through the case Sort of with me mentoring them and then they teach the faculty and the rest of the group About the particular issue. So the interesting thing that's happened is that they then go to other hospitals And say are we doing ethics M&Ms here? And so the funding I got was to now do this sort of across the city and potentially across disciplines And hopefully wider but the I think the point that you made about sort of measuring things You know when you apply for funding for this kind of things They want you to measure and the educational theory that I'm using is called transformative learning And so it's really just to do some qualitative research on how Residents our faculty are just changing in their culture It's very palpable to me when I'm in the M&Ms to see how even in my small group of 10 surgeons The culture has changed and in fact at cases that I'm not Present they're discussing ethics and so to me that's sort of the end goal And I think it's I'm really focusing on the residents And students teaching the faculty to feel comfortable with this. So that is fantastic. Thank you. Thanks everybody