Ethics Education in Family Medicine Training in the United States:

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Ethics Education in Family Medicine Training in the United States: a National Survey

Helen M. Manson, MBChB MRCGP; David Satin, MD; Valerie Nelson; Thenmalar Vadiveloo BACKGROUND AND OBJECTIVES: Although professional organizations endorse ethics education in family medicine training, there is little published evidence that ethics teaching occurs. This survey collated data on the aims, content, pedagogical methods, assessment, and barriers relating to formal ethics education in family medicine residency programs in the United States. METHODS: A questionnaire surveyed all 445 family medicine residency programs in the United States. RESULTS: Forty percent of programs responded (178/445). Of these, 95% formally teach at least one ethics topic, 68.2% teach six or more topics, and 7.1% teach all 13 core topics specified in the questionnaire. Programs show variation, providing between zero to 100 hours’ ethics education over the 3 years of residency training. Of the responding programs, 3.5% specify well-defined aims for ethics teaching, 25.9% designate overall responsibility for the ethics curriculum to one individual, and 33.5% formally assess ethics competencies. The most frequent barriers to ethics education are finding time in residents’ schedules (59.4%) and educator expertise (21.8%). CONCLUSIONS: Considerable variation in ethics education is apparent in both curricular content and delivery among family medicine residency programs in the United States. Additional findings included a lack of specification of explicit curricular aims for ethics teaching allied to ACGME or AAFP competencies, a tendency not to designate one faculty member with lead responsibility for ethics teaching in the residency program, and a lack of formal assessment of ethics competencies. This has occurred in the context of an absence of robust assessment of ethics competencies at board certification level. (Fam Med 2013;46(1):28-35.)

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thical challenges occur frequently in the daily work of a family physician. In 2008, a needs analysis described the “inherent uncertainties, wide-ranging responsibilities, and broad scope of family medicine that generate ethical complexity,” and outlined compelling reasons why ethics education 28

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must be an essential component of family physician training.1 Despite the strong evidence-based need for ethics education, recognized globally by professional organizations in family medicine, there were indications that ethics teaching was not being provided in residency programs. This study is the first to survey all family

medicine residency programs in the United States, aiming to: (1) assess the extent of ethics education in family medicine training and (2) gather and share pedagogical information on aims, content, methods, resources, assessment techniques, and barriers to ethics education. The overall purpose of the survey is to provide a “snapshot” of the status quo of ethics teaching in family medicine training and to determine ways in which this could be improved. There are some general guiding principles in the published literature that help to define expected standards for ethics education in family medicine residency. It is well recognized that ethics teaching must: • be integrated throughout medical training, building on the ethics education received in medical school and continuing into residency, • aim to “custom-fit” the learner’s needs at different stages of medical training, as new roles and responsibilities provide new ethical challenges, and • address the particular ethical issues that occur in the resident’s chosen specialty.2,3 This indicates that ethics education should be longitudinal throughout the family medicine residency, aiming to equip residents to

From the Dundee University School of Medicine, Dundee, Scotland (Dr Manson and Ms Vadiveloo); and Department of Family Medicine and Community Health, University of Minnesota (Dr Satin and Ms Nelson).

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specifically manage ethical issues that arise in family medicine. Specifying the goals of an educational program is a fundamental principle of good educational practice that assists educators in the planning of teaching, clarifies expectations for learners, and determines appropriate assessment strategies.4,5 The needs analysis paper proposed a set of overall aims for ethics education in family medicine (Table 1), based on guidance from family medicine training organizations and studies on residency ethics education in primary care.1 In the United States, the Accreditation Council for Graduate Medical Education (ACGME) requirements for family medicine training incorporate ethics objectives throughout all six core competency domains, extending well beyond the “Professionalism” domain.6 We have assembled a table showing the areas within each ACGME competency related to ethics education (Table 2). Although there is a lack of published studies on ethics education, specifically in the family medicine training setting,1 studies in residency programs for other specialties have endorsed the need for: • predetermined learning objectives, • an explicit and planned curricular design, • mandatory participation by residents, • formal assessment of attitudes, knowledge, and skills, • assigned faculty with responsibility for the ethics curriculum, • protected curricular time,

• case-based, small-group discussions as the preferred teaching method and • ethics ward rounds and rolemodeling by faculty to encourage horizontal integration.7-11 The development of skills for ethical reasoning and decision-making is recognized as an important goal of ethics education,12-14 and use of a framework for ethical analysis can provide a structure to help learners and educators identify and discuss clinical ethical issues.15-17 Use of the humanities (philosophy, literature, arts, history) is another well-established method of teaching ethics that can increase interest and engagement for medical learners.18 In 2008, the American Academy of Family Physicians (AAFP) incorporated many of these educational principles into recommended curriculum guidelines (endorsed by the Association of Departments of Family Medicine, Association of Family Medicine Residency Directors, and the Society of Teachers of Family Medicine).19 This eight-page document provides suggested aims (in terms of competencies, attitudes, skills, and knowledge), maps competencies to ACGME outcome domains and provides a short list of teaching and learning resources (books, web sites and AAFP Home Study modules). The AAFP guidelines, however, provide no guidance on the assessment of ethics competencies within family medicine residency training. This background information enabled the construction of a questionnaire for use as a survey tool for this study and provided the standards

against which the survey results were compared.

Methods

The appropriate human subjects’ protection committees at the University of Dundee and the University of Minnesota granted the study exemption from formal review.

Survey Development

A survey tool was developed, for completion by the program director or principal ethics educator in the residency. The respondent was initially invited to indicate the ethics topics taught formally in the program, choosing from a checklist of 13 core ethics topics. “Formal” teaching was defined as “taught according to a prearranged schedule with content and teaching methods carefully considered and planned ahead of time.” If any one ethics topic was taught formally, the respondent continued on to answer 11 further questions about the residency’s ethics teaching, constituting 47 question items in all. The 13 core ethics topics were derived from the overall aims of family medicine ethics training described in the needs analysis paper (based on aims published by the Royal College of General Practitioners of the United Kingdom, the College of Family Physicians of Canada, and studies describing ethics education in family medicine and primary care training programs),1 combined with the main topic areas listed in the AAFP guidelines.19 The questionnaire was tested for general ease of understanding by five family medicine residency program directors, revised to adjust the

Table 1: Overall Aims of Medical Ethics Education in Family Medicine Training • Recognition of the scope of ethical issues in family medicine • Awareness of values (self/patient/societal/professional/conflicting values) • Development of analytical and reasoning skills based on knowledge of ethical principles, professional obligations, and the law • Development of communication skills to enhance the doctor-patient relationship and to resolve conflict • An understanding of distributive justice, health resource allocation, and the role of the physician in advocating for organizational change Source: Manson H.1

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Table 2: ACGME Requirements for Family Medicine Related to Medical Ethics Patient Care: continuity of care and comprehensive care (including physician availability, accessibility, efficiency, and continuity); responsibility for the total health care of the individual and family (social, behavioral, economic, cultural, and biologic dimensions); cultural competence in caring for patients from varied ethnic and cultural backgrounds; provision of longitudinal health care, including assisting in coping with serious illness and loss; family care (genetic counseling, aging, end-of-life issues, the role of family in illness care, family counseling, and safety). Medical Knowledge: sociocultural parameters of patients and the greater community; psychosocial impacts of pregnancy, delivery and care of the newborn; genetic counseling; options counseling for unintended pregnancy; physician-patient relationship; patient interviewing and counseling skills; assessment of risks for abuse, neglect, and family/community violence; factors associated with differential health status among sub-populations, including racial, geographic, or socioeconomic health disparities, and the role of family physicians in reducing such gaps; participation in projects to improve quality of care; impact of new technologies on practice, determining value in the marketplace, assessing customer satisfaction, measurement of clinical quality, tort liability, and risk management. Practice-based Learning and Improvement: identify strengths, deficiencies, and limits in one’s knowledge and expertise; set learning and improvement goals; identify and perform appropriate learning activities; analyze practice using quality improvement methods, implement changes with goal of practice improvement; incorporate formative evaluation feedback into daily practice. Interpersonal and Communication Skills: communicate effectively with patients, families, and the public across a broad range of socioeconomic and cultural backgrounds and with physicians, other health professionals, and health-related agencies; work effectively as a member/leader of a health care team; maintain comprehensive, timely, and legible medical records. Professionalism: commitment to carrying out professional responsibilities and adherence to ethical principles; demonstrate compassion, integrity, and respect for others; responsiveness to patient needs that supercedes self interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population, including diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. Systems-based Practice: Awareness of and responsiveness to the larger context and system of health care; ability to call effectively on other resources in the system; work effectively in various health care delivery settings and systems; coordinate patient care; incorporate considerations of cost awareness and risk-benefit analysis in patient- and/ or population-based care as appropriate; advocate for quality patient care and optimal patient care systems; work in interprofessional teams to enhance patient safety and improve patient care quality; participate in identifying system errors and implementing potential solutions; skills for career-long professional learning; ability to educate patient and family about diagnoses, evaluation, and treatment of the disease, and to obtain informed consent; ability to practice in a team; cost-conscious ordering of diagnostic tests and therapeutics; construction of a medical record summary with accuracy and in compliance with the hospital’s medical records policies; provide guidance to patients regarding advanced directives, endof-life issues, and unexpected diagnoses/outcomes. Resident Duty Hours in the Learning and Working Environment: Demonstrate an understanding and acceptance of personal role in: assurance of the safety and welfare of patients entrusted to care; provision of patient- and familycentered care; assurance of fitness for duty; management of time before, during, and after clinical assignments; recognition of impairment, including illness and fatigue in self and in peers; attention to lifelong learning; the monitoring of patient care performance improvement indicators; honest and accurate reporting of duty hours, patient outcomes, and clinical experience data. ACGME—Accreditation Council for Graduate Medical Education Source: Information extracted from ACGME Program Requirements for Graduate Medical Education in Family Medicine Education6

clarity of the questions, and tested again by two of the same program directors. Respondents were invited to provide additional information about the residency ethics curriculum, either as free-text responses or as extra documents returned with the questionnaire to the study team. On the questionnaire, permission was requested to share the documents

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with other educators on the Family Medicine Digital Resource Library (FMDRL).20

Data Collection

In March 2010, the study investigators mailed a survey questionnaire and cover letter to all 450 family medicine residency programs registered with the Society of Teachers of Family Medicine, coding each

questionnaire with a programspecific three-digit tracking code to facilitate the identification of non-respondents for follow-up. These codes remained confidential, and study investigators were blinded to these, to preserve respondent anonymity. Additional mailings were sent to nonresponding sites 6 weeks later and again after a further 3 weeks.

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Data Analysis

Descriptive statistics provided summaries of each question in the survey. Responses to categorical questions were summarized as percentages and number of responses. The chi-squared test was used to investigate the association between responses to categorical questions and certain characteristics of interest: all chi-squared results are described in the text of this paper. As the study emphasis was to evaluate formal ethics education, the combined responses of those who noted ethics teaching as “formal” or “both formal and informal” were analysed. All analyses were carried out using statistical software SPSS (SPSS Inc, Chicago, v17.0). The study investigators reviewed responses regarding program aims to assess: presence of an overall broad statement of purpose, expression using Bloom’s taxonomy (specifying actual tasks)21 or as competencies (specifying professional roles/activities), explicitness as a medical ethics thread, alliance to published learning objectives, and comprehensiveness.

Results

Of the 450 family medicine residency programs contacted, five had closed. Forty per cent (178/445) of the questionnaires were completed and returned to study investigators. Of these, 139 (78.0%) were completed by program directors (including two assistant program directors) and 19 (10.7%) by “educators in medical ethics in the family medicine residency.” Twenty respondents (11.2%) were faculty in behavioral sciences or family medicine, and two chaired the local Ethics Committee. Eighteen respondents (12.9%) described a dual role as program director and ethics educator.

Content and Timing of Ethics Education

Figure 1 shows the number of ethics topics taught. Eight of the 178 responding programs (4.5%) do not formally teach any of the topics listed on the survey questionnaire. FAMILY MEDICINE

Figure 1: Core Ethics Topics Taught Formally

Number of topics that are taught as formal course

Ninety-five percent of respondents (170/178) teach at least one of the ethics topics listed on a formal basis. Of the programs that undertake formal teaching, 116 (68.2%) teach six or more topics, and 12 (7.1%) teach all 13 subjects. Table 3 shows the ethics topics taught by responding programs. Of those topics formally taught, the most common include professional codes of conduct, legal aspects relevant to family medicine, end-of-life issues, and communication skills related to ethical issues (60%–70% of responding programs). Formal teaching on cost considerations and the implications of values in practice occurred least often (38.4% and 40.3%, respectively). Free-text responses indicated teaching on some topics not listed in the survey, such as theories of ethics, history of medical ethics, “discourse ethics,” ethics of spiritual care, eugenics, “boundary violations,” “value clarification (birth control, terminations),” Hippocratic Oath, attendance at the Ethics Committee, “pediatric issues,” confidentiality, “reproductive issues,” “genetic issues,” and Institutional Review Board training.

Most commonly (88 programs, 51.8%), between 4 and 10 hours of formal ethics teaching is provided during residency training. Teaching tends to be spread across 3 years of residency (117/170, 68.8%) rather than occurring in any one year.

Aims of Ethics Education

Fifty-eight of 170 programs that formally teach ethics indicated that they have defined aims for ethics teaching (34.1%). Fifty-five respondents provided more detail on the program’s aims through free-text responses or by returning documents with additional information. In the majority of these programs, we considered the aims to be vague, limited in scope, or not specific to family medicine. For example, objectives were often expressed only for individual lectures or represented goals for ethics education for the hospital or university rather than for the residency program. Six programs (3.5% of those formally teaching ethics) were found to have appropriately constructed, well-defined, comprehensive learning objectives. These training programs clearly describe the expected ethics competencies of the residents at the end of their family medicine


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Table 3: Ethics Topics Taught in Family Medicine Residency Programs Formal† Teaching

Informal‡ Teaching

n (%)*

n (%)*

Professional attitudes and behavior

87 (49.4)

44 (25.0)

45 (25.6)

The content of professional codes of conduct

116 (66.3)

48 (27.4)

11 (6.3)

The meaning of ethical principles (respect for autonomy, beneficence, avoidance of harm, justice)

100 (56.8)

53 (30.1)

23 (13.1)

The scope of ethical issues relevant to family medicine (ie, the range of ethics topics relevant to the practice of family medicine)

75 (42.6)

69 (39.2)

32 (18.2)

The implications of values in practice (of doctor/patient/society, diversity of values, and the implications of conflicting values)

71 (40.3)

77 (43.8)

28 (15.9)

Legal aspects relevant to the practice of family medicine

113 (65.3)

29 (16.8)

31 (17.9)

Issues related to mental capacity and giving informed consent

103 (58.5)

41 (23.3)

32 (18.2)

Implications of commercial conflicts of interest

78 (43.8)

76 (42.7)

24 (13.5)

Communication skills related to ethical issues (eg, defining patients’ values, giving bad news, negotiating a compromise, etc)

121 (68.4)

18 (10.2)

38 (21.5)

Practice in the context of cost considerations and the judicious use of health care resources

68 (38.4)

68 (38.4)

41 (23.2)

End-of-life issues

126 (71.2)

8 (4.5)

43 (24.3)

Importance of participation in mechanisms to maximize patient safety

91 (52.0)

49 (28.0)

35 (20.0)

Research ethics

97 (57.4)

61 (36.1)

11 (6.5)

No Teaching n (% )*

* Percentage of all responding programs † “Formal” teaching: taught according to a prearranged schedule, with content and methods carefully considered and planned ahead of time. ‡ “Informal” teaching: not planned but opportunistically picked up by residents

training, and three of these programs use Bloom’s Taxonomy21 to specify objectives. Three programs explicitly align their program’s ethics aims with ACGME outcomes, and two created a “hybrid” set of aims, combining ACGME outcomes with the AAFP curricular guidelines. Five programs separate out aims explicitly as a medical ethics thread in the curriculum, with one program labelling this the “Medical Ethics and Humanities Curriculum.”

Teaching Methods

The most common teaching methods are case discussions and lectures, followed by small-group discussions (Table 4). Three or more teaching modalities are used in 129 of the 170 programs (75.8%). Details have been made available on FMDRL describing specific humanities resources 32


(stories, movies and poems) and online learning resources (involving institutional, university, state, and commercial websites) used by educators to teach ethics.20

In 44 programs (25.9% of those teaching ethics formally), one person has overall responsibility for the ethics curriculum. Up to five educators are involved in teaching ethics in

Table 4: Methods Used to Teach Ethics in Family Medicine Residency Programs n (%)* Discussion of cases

138 (81.2)

Lectures

137 (80.6)

Small-group discussions

115 (67.6)

Other teaching method

49 (28.8)

Stories

47 (27.6)

Movies

34 (20.0)

Online educational modules

32 (18.8)

Study guide/s

8 (4.7)

Poems

9 (5.3)

* Percentage of all responding programs

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61% of residency programs (104/170). The majority of those who teach ethics are either physicians (126/170, 74.1%) or have a PhD (80/170, 47.1%). Other ethics educators include faculty in palliative care or geriatric medicine, chaplains or clergy, or staff with qualifications in nursing, social work, ethics, law, pharmacology, psychology, or philosophy. Chi-squared analysis tested the association between certain characteristics of interest related to single or multiple educators (Table 5).

Assessment

Attendance at ethics teaching is mandatory for residents in 118 programs that teach ethics formally (69.4%). Formal assessment of ethics outcomes occurs in 57/170 programs (33.5%). In 33 of 170 programs

(18.5%), formal assessment is performed in all three domains of attitudes, knowledge, and skills. Table 6 shows the format of assessment used by residency programs. Multi-source assessment includes feedback from a variety of individuals, including the resident’s advisor, faculty, attending physicians, preceptors, nurses, peers, self, office staff, and, in two programs, patients. Additional assessment methods stated by single programs included: case discussion; advisor meetings, six monthly “Education Prescription Plans,” role-playing, videotaping, chart audit, a “Portfolio Exhibit,” Objective Structured Clinical Examination, standardized patients with feedback using a structured tool, and a “Professionalism Inventory.”

Programs that had stated aims for ethics teaching were not more likely to assess ethics outcomes than those that did not state aims (c2=0.515, P=.473); however, this analysis included the large number of programs with aims assessed as deficient. The number of programs with well-defined aims (6/170, 3%/5%) was too small to permit a correlation with assessment to be evaluated. Similarly, there was no correlation between programs teaching more ethics across residency training (>11 hours) and formal assessment of ethics outcomes (c2=0.503, P=.478).

Perceived Effectiveness of Ethics Curriculum

Eighty-seven respondents (51% of those teaching ethics formally) indicated that their residents were better

Table 5: Programs With a Single Ethics Educator With Responsibility for Ethics Teaching Versus Multiple Educators Single Lead Ethics Educator Versus Multiple Educators

Chi-squared Value (c2)

P Value*

Are six or more topics likely to be taught?

2.922

.087

Is ethics more likely to be formally assessed?

2.104

.147

Are there likely to be defined aims for ethics teaching?

0.985

.321

Are there likely to be more hours of ethics teaching?

4.494

.106

Are ethical frameworks more likely to be used in teaching?

5.194

.023

Professional attitudes and behaviour

2.206

.332

Content of professional codes of conduct

4.917

.178

Meaning of ethical principles

18.383

11 hours) during the residency and a perception that residents were able to identify or deal with ethics issues in practice (c2=0.972, P=.324). In addition, there was no significant difference between the responses of program directors (c2=2.597, P=.107) and other educators (c 2=0.047, P=.829) in the perceived value of ethics education for residents.

Barriers to Ethics Education

The main barriers to formal ethics education involved assigning time in the residents’ schedule (101/170, 59.4%) and finding educators with the appropriate knowledge (37/170, 21.8%).

Discussion

Prior to this study, there was little evidence of formal ethics education in family medicine residency training in the United States and limited information as to how training programs approached this required teaching. Although the extent of ethics teaching is still unknown in 267 nonrespondent programs, 95% of the respondents to this study (170/178) indicate the teaching of at least one ethics topic on a formal basis, and 68.2% (116/170) teach six or more ethics topics. Only 7.1% of programs formally teach all of the ethics topics recommended in published guidelines, and eight responding programs report no formal ethics teaching at all in their programs. Although no 34


Table 6: Format of Ethics Assessment in Family Medicine Residency Programs n (%)* Multiple sources of assessment

41 (24.1)

Multiple-choice questions

12 (7.1)

“Rotation evaluations”

6 (3.6)

Essay

3 (1.8)

Faculty observation

3 (1.8)

* Percentage of all responding programs

definite conclusions can be drawn about the programs that did not respond to the survey, we believe that programs providing more robust formal ethics teaching were more likely to respond to the survey than those that did not. Therefore, there are likely to be more programs that do not teach ethics at all, or that do so in a limited fashion, in the non-respondent group. As well as the variation in the range of topics taught, this study shows significant variability in the number and content of curricular hours dedicated to ethics education between residency programs. Despite the pedagogical imperative to specify predetermined learning outcomes for a curriculum,4,5 of 170 programs that teach ethics formally only 3.5% had well-constructed curricular aims for ethics teaching. Even fewer respondents allied their program’s ethics aims with ACGME outcomes or with AAFP curricular guidelines. Although “Professionalism” is one of the six ACGME outcomes domains, only 15 of 170 residencies that teach ethics formally (8.8%) specify professionalism-related learning outcomes within the program’s aims. In addition, learning outcomes such as communication skills related to ethical issues, cultural competence, and legal aspects of practice were generally not included as aims. The most common barriers to ethics education involved finding time in residents’ schedules (59.4%) and educator expertise (21.8%). Although finding time in residents’ schedules

is an expected barrier for any educational subject, difficulty in finding educators with the appropriate knowledge is possibly unique to teaching this required subject: imagine one out of five programs reporting a lack of expertise in cardiology teaching. Previous studies have recommended the assigning of faculty with specific responsibility for residency ethics teaching.8,11 This study suggests that a single ethics educator with responsibility for the ethics curriculum increases the likelihood that certain important ethics topics are taught formally (ie, the meaning of ethical principles, the scope of ethical issues relevant to family medicine, implications of values in practice, and communication skills related to ethics issues) and that an ethical analysis framework is more likely to be used. However, only 25.9% of programs teaching ethics formally (44/170) have an ethics educator to lead this teaching. It is well established that assessment is a fundamental principle of educational practice, “a tool to ensure quality in training programs, to motivate students and to direct what they learn.”22 Nonetheless, this study has uncovered a lack of formal assessment in ethics competencies in family medicine residency programs, with only 33.5% of respondents using any formal means of assessment. In the United Kingdom and Canada, trainees are required to demonstrate competence in ethics outcomes before becoming board certified as a family physician,23,24 but this is not yet the case in the United States.

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It is possible that there is a lack of incentive for formal assessment in individual programs, related to the absence of assessment in ethics outcomes at the board certification level. In interpreting the data from this study, it is important to bear in mind that the respondents were self-reporting: each questionnaire was likely completed on the basis of one individual’s memory of their program. This may have influenced the accuracy of the details reported, although the extent of this is difficult to gauge. Another limitation relates to an oversight, the omission of “confidentiality” from the survey’s list of core ethics topics. It is possible that more programs would have indicated that confidentiality was taught if this had been listed separately. Overall, this study indicates considerable heterogeneity in curricular content and delivery of ethics education among the responding family medicine residency programs. There are also notable areas requiring improvement: (1) the lack of specification of explicit curricular aims for ethics teaching, allied to ACGME or AAFP competencies, (2) the tendency not to designate one faculty member with lead responsibility for ethics teaching in the residency program, and (3) the lack of formal assessment of ethics competencies. This occurs in the context of an absence of robust assessment of ethics competency before qualification as a fully fledged family physician. The study has also collated and posted educational materials to share with family medicine educators on FMDRL (www.fmdrl.org) as a way of enabling the teaching of family medicine ethics. Further useful research would involve the evaluation

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and sharing of ethics teaching ideas and assessment methods in the family medicine training setting, so that other residency programs may benefit from creative, effective pedagogical practice. ACKNOWLEDGMENTS: Financial support was provided by the Society of Teachers of Family Medicine Group Project Fund. CORRESPONDING AUTHOR: Address correspondence to Dr Manson, Dundee University School of Medicine, c/o MACHS 2, Ninewells Hospital, Dundee DD1 9SY, Scotland, United Kingdom. (01144)-1382-496695. Fax: (01144)1382-632597. [email protected]

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10. Diekema DS, Shugerman RP. An ethics curriculum for the pediatric residency program: confronting barriers to implementation. Arch Pediatr Adolesc Med 1997;151(6):609-14. 11. Schuh LA, Burdette DE. Initiation of an effective neurology resident ethics curriculum. Neurology 2004;62(10):1897-8. 12. Pellegrino ED, Hart RJ, Henderson SR, Loeb SE, Edwards G. Relevance and utility of courses in medical ethics: a survey of physicians’ perceptions. JAMA 1985;235(1):49-53. 13. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical ethics education: where are we? Where should we be going? A review. Acad Med 2005;80(12):1143-52. 14. Myser C, Kerridge IH, Mitchell KR. Teaching clinical ethics as a professional skill: bridging the gap between knowledge about ethics and its use in clinical practice. J Med Ethics 1995;21:97-103. 15. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine, fifth edition. New York: McGraw-Hill, 2002. 16. Alfandre D, Rhodes R. Improving ethics education during residency training. Med Teach 2009;31(6):513-7.

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5. Grant J. Principles of curriculum design. In: Swanwick T, ed. Understanding medical education: evidence, theory and practice. Oxford, UK: Wiley-Blackwell, 2010:9-11. 6. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in family medicine education. July 1, 2007. http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007. pdf. Accessed October 6, 2012. 7. Sulmasy DP, Marx ES. Ethics education for medical house officers: long-term improvements in knowledge and confidence. J Med Ethics 1997;23(2):88-92. 8. Levin AV, Berry S, Kassardjian CD, Howard F, McKneally M. “Ethics teaching is as important as my clinical education:” a survey of participants in residency education at a single university. Univ Toronto Med J 2006;84(1): 60-3. 9. Berseth CL, Durand R. Evaluating the effect of a human values seminar series on ethical attitudes toward resuscitation among pediatric residents. Mayo Clin Proc 1990;65:337-43.

19. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents: medical ethics. AAFP reprint no. 279. Revised version. Leawood, KS: American Academy of Family Physicians, 2008. 20. Society of Teachers of Family Medicine. Family Medicine Digital Resource Library. www.fmdrl. org. Accessed October 6, 2012. 21. Taxonomy of educational objectives, handbook I: The cognitive domain. New York: David McKay Co Inc, 1956. 22. Shumway JM, Harden RM. AMEE guide no. 25: The assessment of learning outcomes for the competent and reflective physician. Med Teach 2003;25(6):569-84. 23. Royal College of General Practitioners. The learning and teaching guide. Version 3.3. London: Royal College of General Practitioners, 2009. 24. College of Family Physicians of Canada. Standards for accreditation of residency training programs. Toronto: College of Family Physicians of Canada, 2006.


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