Residents must begin to integrate ethical aspects into their daily clinical practice1,2; however, teachers are often uncomfortable talking about ethics with residents and have difficulty raising this topic during clinical supervision. To support residents’ ethical reflection, clinical teachers first need to recognize the ethical aspects of a given situation. They must also make room for ethics within the limited time available during supervision. This article offers a 3-step approach and a number of teaching methods that are easy to incorporate into clinical supervision.
Three-step approach for supervisors
Step 1: Identify the ethical aspects of the situation
We often associate ethics with conflicts around values or dilemmas around life-and-death decisions. And yet there is an ethical component to every medical decision that a physician shares with a patient when the physician is acting out of concern for the patient’s best interests. For example, when deciding whether to order a test that is not widely available, or when a patient is not complying with treatment, a clinician will include an ethical reflection in his or her decision process.
Ethical issues are in fact very common in clinical practice. It is up to the supervisor to identify these issues when directly supervising a resident or when the resident presents his or her consultation with the patient. If the supervisor takes the time to investigate the ethical dimensions, he or she will become skilled at recognizing them and at discussing them during daily periods of supervision. Box 1 provides a list of topics that have ethical aspects that could be raised and discussed during clinical supervision.
Ethical issues for discussion during clinical supervision
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Resource allocation and the family physician’s role as gatekeeper of the health care system
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Relationships with specialist colleagues; family physician colleagues; colleagues in other fields
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Incompetent colleagues
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Colleagues in crisis
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Continuity of care and on-call responsibilities
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Confidentiality and privacy
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Potential problems with electronic medical records
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Gifts from patients; patients as friends; sexual impropriety
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The doctor-patient relationship and its challenges (transference-counter-transference); relationship with the patient’s family
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Noncompliance with treatment
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Decision making on behalf of another; incompetence; informed consent
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Relationships with the pharmaceutical industry; conflicts of interest
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Medical research (recruiting patients, scientific integrity, use of placebos)
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Reproductive issues; fertility; contraception; abortion
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Genetics issues; diagnostic testing; presymptomatic screening
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End-of-life issues; euthanasia; physician-assisted suicide
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Medical error; reporting responsibilities
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Cross-cultural issues
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Medical ethics and the medical and professional standards governing our profession
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Professionalism, values, and principles inherent in the role of the physician (empathy, intellectual honesty, respect, accountability, prudence, etc)
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Critical incidents, conflicting values, conflicts with patients and other stakeholders
Step 2: Choose to raise ethical issues during this supervision time
There are many reasons why ethics are overlooked during clinical supervision. These include workload, time pressures, the specific learning needs of residents, and a tendency on the part of clinicians to stay within their comfort zone or to steer supervision toward their personal areas of expertise.3
To ensure that the learning of ethics is integrated into the resident’s experience, the supervisor must consciously decide to make ethics a priority and to take advantage of opportunities to address it.
Step 3: Find a way to address the ethical dimension of a situation and to encourage the residents
There are many tools to encourage discussions on ethical issues4,5; however, they are generally difficult to adapt to clinical supervision. We propose 2 ways to raise the issue of ethics and to structure a discussion around ethics during clinical supervision. The first is a set of 3 questions to ask the resident. The second is a visual aid; it features the triangle formed by the 3 determinants in the clinical decision: the physician, the patient, and the context. These 2 approaches can be used together or separately, depending on the situation and the affinities and preferences of the supervisor or the resident (Figure 1).*
Three questions
Here are 3 simple questions that the supervisor can use to help the resident reflect on the clinical situation and to encourage discussion.
What is the meaning of my action?
Is the medical procedure that I am about to perform, and the medical decision I am about to share with this patient, appropriate for him, for me, for others, and for the society in which we live? For example, at this point in his life, does it make sense to prescribe antihypertensive medication to this 80-year-old patient? What are my treatment goals? What are the patient’s treatment goals? Are these goals based on principles found in the scientific literature, my personal beliefs, or what the patient wants? What about the society that will absorb the cost of this medication? This question will help the resident to understand the issues involved in clinical decision making, the expectations of the physician and the patient, the factors that influence decision making, and so forth.
Something does not feel quite right. What is it?
Why can’t the patient and I agree? Why do I feel uncomfortable around this patient? Why is it difficult to say yes to this patient when I have not had any difficulty saying yes in other circumstances? When I think about what is happening in this consultation, what values and powers are conflicting with one another? This question makes it possible to pinpoint the discomfort in a given clinical situation, identify its origin, articulate the problem, and resolve it.
What are my limits?
Just how far should I go in this situation, with this patient? What is the most reasonable and desirable decision? How do I care for the patient while looking after myself? How do I honour my values, time constraints, and availability? When you ask yourself what your limits are, you are asking what is possible. The question also brings the resident face to face with his professional ideals. It might reassure a resident who would not dare to take on a problem that seems too onerous and it might help a resident who has a tendency to take on too much.
The triangle
Another approach to the clinical supervision of the ethical dimension, which is based on the work of R.B. Haynes, uses a triangle developed by Cécile Bolly6–8 to represent the 3 poles of clinical decisions: the physician, the patient, and the context. The supervisor and the resident can use this triangle to determine the relative importance assigned to each pole in a given clinical situation.
In this triangle, I represents the physician, with his or her knowledge, experience, and values. You is the patient who has his own understanding of the illness, based on his knowledge, beliefs, and personal history. They represents our colleagues, the institution in which we work, medical science, the practice guides, society and its health system, and so forth. The exploration of ethics is at the centre of the triangle; in a difficult situation, linking these 3 elements might make it possible to break an impasse.8
The triangle can be drawn to reflect the forces at work in a given clinical situation; with the resident, the supervisor can then review what happened during his consultation with the patient, as well as the pitfalls of allowing 1 of the 3 forces to dominate. The purpose of this discussion is not necessarily to bring the 3 forces into perfect balance; rather, it is to understand the issues in order to make the best possible decision under the circumstances.
Consider the example of a resident who applies a practice guide recommendation rigidly, without taking the patient’s unique situation and objections into account. I and they now dominate, to the detriment of you. The physician (I) might believe that a standard recommendation is justified because it reflects medical science (they). In this process, the patient (you) has been eclipsed and is no longer part of the decision-making process. At this point, the supervisor can ask the resident to think about the potential risks of this course of action: patient dissatisfaction, noncompliance, etc.
Now consider the example of a resident who is so focused on the patient’s demands that he or she prescribes a test or treatment that he or she believes is unnecessary. Here, the you will dominate, to the detriment of I and they. At this point, the supervisor would begin a discussion about the potential risks of a decision that relies too heavily on the patient’s wishes and beliefs: a scientifically unfounded or inadequate treatment decision.
This clinical decision-making tool does not tell you what to do7; it helps you to think about a clinical situation in order to understand it more fully, becoming aware of the roles of each stakeholder and the causes, risks, and consequences of an imbalance. Most important, it helps you to think about alternatives. It can also be used to explore ethical issues, imagining what would happen if one stakeholder was given priority over the other two. Figure 1* illustrates these possibilities.
Conclusion
This 3-part approach is a tool that clinical supervisors can use to explore ethical issues with their residents. They will find it easy to incorporate this tool, asking questions and exploring the possible consequences of various clinical decisions. However, the tool will only help if the supervisor takes the first step, making an effort to identify the clinical issues in a given clinical situation, and chooses to talk about this with his residents.
Notes
TEACHING TIPS
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Teachers are often uncomfortable talking about ethics with their residents and have difficulty raising this topic during clinical supervision.
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This 3-step approach and these teaching methods are easy to apply in clinical supervision.
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In order for this approach to work, the supervisor must take the first step, identifying the ethical issues in a given situation and deciding to address them.
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Miriam Lacasse, Teaching Moment Coordinator, at Miriam.Lacasse{at}fmed.ulaval.ca.
Footnotes
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La version en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de juillet 2013 à la page 795.
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↵* Figure 1 is available at www.cfp.ca. Go to the full text of the article online, then click on CFPlus in the menu at the top right-hand side of the page.
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Competing interests
None declared
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