J Dent Educ. 72(12): 1450-1457 2008
© 2008 American Dental Education Association
Critical Issues in Dental Education |
What Do Dental Students Learn in an Ethics Course? An Analysis of Student-Reported Learning Outcomes
Helen M. Sharp, Ph.D.;
Raymond A. Kuthy, D.D.S.
Key words: integrity, professionalism, ethics education, assessment, outcome, effectiveness
Submitted for publication 05/22/08;
accepted 08/19/08
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Abstract
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The purpose of this article is to report first-year dental students’ perceptions of their primary learning outcomes from a course in ethics and professionalism. Students were asked to identify one topic or theme from the course that might influence their professional practice. Responses from 232 students were analyzed according to the explicit topics taught in the course. The most commonly identified topics were confidentiality (21 percent), informed consent (21 percent), and obtaining assent from children and adolescents (19 percent). An ad hoc analysis of students’ narratives provides preliminary evidence that students perceive an increased awareness of their role and obligations as a professional immediately after a course in ethics and professionalism. The long-term influence of coursework in ethics and professionalism remains unknown.
Ethics and professionalism are core components of the curriculum in accredited dental programs.1 In the past few years, several dental schools have made headlines for substantive breaches of ethical conduct among students.2,3 These incidents have furthered academic questions about the purpose of ethics within the curriculum and whether these courses really foster ethical and professional behavior among students.4
Bertolami levied three primary criticisms at ethics curricula: "more education is not the answer to everything, ethics is boring, and course content is qualitatively inadequate" to achieve true behavior change (p. 416).4 Further, he claimed that dental students bring ethics with them and that "no one has ever done the right thing because of taking an ethics course in dental school" (p. 414). Questions about the effectiveness of ethics education are not new to higher education;5 however, contemporary breaches of ethics have renewed these questions in dentistry6–10 and medicine.11 Despite the concerns and heightened criticism, no one has yet suggested abandoning ethics education in clinical professional training programs. Rather, the primary conclusion is that instructors and administrators must examine the effectiveness of ethics education within the context of the whole curriculum.
In order to evaluate the outcomes of instruction, the goals must be clearly defined.11 While the purpose of teaching ethics and professionalism seems intuitive, statements of the goals of ethics curricula are often vague. The American Dental Education Association (ADEA) policy statements call for formal instruction in ethics and professional behavior with the goal to "make the students aware of acceptable professional conduct in instructional and practice settings."1 Additionally, training programs are required to maintain policies for handling unethical conduct, make students and faculty aware of the profession’s societal obligation, implement appropriate management of patient records, and educate staff, faculty, and students about patients’ rights to confidentiality. The literature espouses broad goals of ethics education for students in professional programs. For example, Ozar argues that a primary goal of ethics education "is to provide dentists with conceptual tools that will help them reflect more clearly on the ethical issues that concern their professional practice" (p. 9).12 Bertolami asks simply, "Wouldn’t a more mature and conscious understanding of one’s own code of life and behavior, including the beliefs underpinning them, constitute a worthwhile goal?" (p. 424).4 Campbell et al. describe the "ideal of the ethical doctor" as someone who has "a commitment to patient welfare," possesses "an ability to deal with complexity and uncertainty," and would be "reflective, empathetic and trustworthy" (p. 432).11 Other desirable qualities of professionals include "integrity, honesty, civic-mindedness, courage, self-sacrifice, ability to communicate clearly, thorough and clear work documentation, and commitment to quality."9
Much of the literature related to the outcomes of ethics education is opinion-driven and at times responsive to high-profile institutional crises. Some authors report outcomes of ethics education by measuring pre- and post-course performance using customized assessment tools.13,14 It is relatively straightforward to measure increased knowledge, but more challenging to measure change in attitude or perceptions of relevance of the material. Relatively little attention has been given to measures of students’ perceptions of the value of ethics courses, although Plemmons et al. address this with respect to a course in research ethics.15
Our goal in this study was to examine first-year dental students’ self-reported perceptions of their own learning after nine hours of ethics instruction.
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Freshman Ethics Curriculum: Underlying Philosophy and Delivery
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The ethics curriculum at the College of Dentistry at the University of Iowa is delivered in multiple parts over the four-year undergraduate training program. First-year students participate in a series of three lectures and three small-group discussion sections in their first semester. The freshman ethics course introduces students to the core principles of bioethics and the issues of privacy and confidentiality, mistakes, truth-telling, decision making capacity, informed consent and refusal, assent in pediatrics and adults who lack capacity, team care and interprofessional conflict, and financial resource limitations. In the third year, students participate in one lecture session and four small-group discussions facilitated by faculty dentists. The faculty facilitators work with the course instructor in seminar sessions prior to the course to develop the cases for discussion and to integrate core ethics content in how they guide students through the analysis of the cases. Senior students participate in a seminar that includes discussion and analysis of several ethics cases as well as faculty-led discussion of ethical issues identified by students following their extramural clinical experiences.
The underlying philosophy of the freshman course is to illustrate the applicability of ethics to the daily practice of dentistry, with a particular focus on the role of student dentists. The lecture portion of the course focuses on building knowledge through direct teaching of terminology, illustrated by cases in dentistry and other clinical fields. The students apply the themes addressed in each lecture in ninety-minute case-based discussions the day after the lecture. The goal of these discussions is to facilitate critical thinking and ethical awareness, identified by Campbell et al. as habituation.11 The cases are developed to represent everyday or routine issues derived from senior students’ experiences,16 discussions with faculty dentists, and the literature.17–19 In addition to the lecture and discussion sections, students complete independent assignments based on their reading of articles from the literature in dentistry and medicine.
Discussion sessions are conducted with twenty-five to twenty-eight students, who are subdivided into groups of six to eight. Each small group tackles one case and presents its case to the larger group. The instructor facilitates the discussions within the small groups by visiting with each group, answering questions, and raising new questions for the students to discuss. After the report from each subgroup, the instructor encourages all students to comment, generate other ideas, and ask questions. This format allows all students to complete an analysis of three or four cases in ninety minutes.
The purpose of this article is to summarize what first-year dental students perceived as the primary learning outcomes from a series of lectures and discussions in ethics and professionalism. These data contribute the students’ perspective to the ongoing discussion about the value of teaching ethics and professionalism in dental school.
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Methods
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Students enrolled in the freshman ethics course between 2005 and 2007 were given a take-home writing assignment to respond to this question: "Choose any topic or theme that we covered during this course, and describe how or why something that you learned might influence or alter your practice as a dental health professional." Students’ responses were de- identified and entered in Microsoft Word. The protocol for analyses of these deidentified data was reviewed and approved by the Human Subjects Institutional Review Board at Western Michigan University.
Qualitative analysis techniques were used to categorize students’ responses according to the topic areas covered in the course (e.g., confidentiality, informed consent). Key word searches were conducted using N6, a qualitative analysis software package.20 N6 allows the investigator to search narrative responses and sort them by common terms. For example, all responses that relate to confidentiality can be grouped by searching "confidential," "confidentiality," "private," "privacy," and "HIPAA." The search terms applied are summarized in Table 1
. Once grouped, responses are reviewed to ensure that the student’s response was appropriately categorized. Here is an example of a hypothetical comment from a student to demonstrate the categorization process: "I learned a lot in the course about confidentiality, consent, truth-telling, and professionalism, but the main thing I learned was how important it is to talk with children and obtain their assent." In this example, the primary response relates to the search term "assent," but the software would also assign this response to the categories of confidentiality, consent, truth-telling, and professionalism. The review process allows the investigator to override the software in cases in which the term was used, but not intended by the writer as a dominant issue.
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Table 1. Summary of search terms used to classify students’ narrative responses by topic as listed in the course syllabus
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Results
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Written responses were obtained for 232 students. Using the topics listed in the course syllabus, 235 responses were coded, reflecting that three students identified more than one primary domain in their response. Percentages are given based on the total number of coded responses.
The topics students identified are summarized in Table 2 together with example narratives to illustrate student-perceived learning in each domain. Confidentiality and informed consent were the most frequently identified learning outcomes (21 percent each), closely followed by assent and issues related to working with children and adolescents (19 percent). All other domains listed in the course syllabus were identified by at least three students, but each of these topics represented 10 percent or less of the total responses. Relatively few students (less than 5 percent) discussed their learning specific to mistakes, breaking bad news, truth-telling, professionalism, resource limitations, or conflicts within the care team.
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Table 2. Frequency of identification of explicit topics as listed in the course syllabus with sample responses to illustrate students’ self-reported learning in each topic area
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Six students (2.6 percent) wrote about issues that were not explicitly listed in the course syllabus. These students discussed a) the importance of trying to understand the patient’s perspective, b) that there are always more than two options to resolve a case, c) that they were influenced by the idea that ethical dilemmas can sometimes be prevented through policy, d) that there are important distinctions between law and ethics, e) the importance of careful documentation, and f) the rationale for universal precautions because patients may not disclose known infectious diseases. Each of these issues was addressed directly in the course, but they were not listed as explicit learning goals. Every case discussion concludes with consideration of what one can learn from the case and how similar cases could be prevented in practice. One student wrote, for example, "At the end of each ethics case . . . we were required to ask ourselves how the situation could have been prevented. I learned some great techniques from those discussions that will help me in practice."
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Discussion
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All 232 freshman dental students reported that they learned at least one thing they perceive is applicable to dental practice during one free-standing ethics course. Sixty percent of the responses related to confidentiality, informed consent, or assent. Each of these topics is a relatively straightforward and uncontroversial aspect of clinical practice. While many of the students came into the class with some understanding of these concepts, their responses appear to reflect a perception of new learning related to the nuances of applying these core concepts in daily practice. For example, one student wrote, "We covered consent forms [and] that made me think about how I would present those in my practice. I hadn’t thought about that before you brought it up; now I am starting to think about when to introduce it, what to put on it, and how to introduce it to patients." Another student wrote, "Although it seemed like common sense to me, I found it interesting to discuss the theme of confidentiality. The article ‘Elevator Talk’ was the spark to my interest. This was one of the topics that I found myself making a mental note to be more aware of how I talk and treat patient information." The student is referring to a required reading "Elevator Talk,"21 which summarizes a study of professionals’ conversations during elevator rides and classifies frank breaches of confidentiality as well as other comments that reflect lack of professionalism. The study was simple but elegant in demonstrating the ease with which professionals unintentionally breach confidentiality and can diminish public trust through careless remarks.
Although nearly all of the students’ responses included reflection on an explicit topic from the course, many of the narratives went beyond the topic and illustrated a heightened awareness of one or more of the underlying goals of education in ethics and professionalism that have been described in the literature.4,9,11,12 Therefore, we conducted an ad hoc review of the students’ narratives to see if their reflections could be mapped to the implicit goals of teaching ethics. Students tended not to use phrases such as "civic-mindedness," "altruism," "courage," or "commitment to quality" in their responses, so software-driven analysis of these themes proved difficult. Therefore, we inspected students’ responses to identify one or more examples of their self-reported learning that was consistent with each of the implicit domains described by Bertolami,4 Masella,9 and Campbell et al.11 These examples are summarized in Table 3. The students’ narrative responses yielded at least one example in each of the domains.
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Table 3. Sample student responses that reflect learning in the domains of professionalism, as described by Bertolami, Masella, Campbell et al., and Ozar
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This study has several substantive limitations. First, the findings reflect students’ responses to one open-ended question in a take-home assignment at the completion of a free-standing series of lectures, small-group discussions, and independent assignments. The students were required to answer this question as part of a class assignment, which may have driven some students to give responses they believed the instructor wanted. In other words, students may have felt that an honest response like "I didn’t learn a thing" would yield a lower grade on the assignment, and they could, therefore, have responded positively to the question but continue to harbor negative perceptions about their learning in the course. While this possibility cannot be refuted, the length and thoughtfulness of the students’ responses together with positive course evaluations and continued communication with them beyond the scope of the course reflect a predominantly positive attitude toward the content and a perception that these students often perceived the course content as applicable to the practice of dentistry.
These data do not allow us to develop recommendations for prioritizing the content that should be included in ethics courses because each student was asked to identify only one area of learning. The frequency with which consent, assent, and confidentiality were identified suggests that students perceive that direct teaching of these concepts is valuable. However, the topics that were identified less often should not be overlooked. For example, very few first-year students (n=6) selected limited resources or issues with insurance coverage. However, this topic was added to the freshman course because a systematic review of the ethical issues reported by fourth-year dental students during extramural rotations reflected that the senior students most often identified ethical issues related to resource-related dilemmas, such as patients’ inability to pay.16 It is not clear why so few freshmen focused on limited resources, but it is possible that these issues are less relevant to preclinical students.
These data suggest that most students perceived that they learned content knowledge and how to apply that knowledge to cases discussed in a classroom; however, we can make no claims about whether students retain, habituate, or act on this knowledge,11 nor can we refute Bertolami’s statement that "no one has ever done the right thing because of taking an ethics course in dental school" (p. 414).4 We do not contend that nine hours of ethics instruction in the first semester of dental school is adequate to achieve permanent behavioral change. Nevertheless, several students made pledges of future behaviors or practice patterns they plan to follow. For example, one student wrote, "The discussion [about confidentiality] provoked me to think about the layout of my future practice." Additional examples of anticipated future behaviors are represented in students’ responses in Tables 2
and 3. At this time we have no mechanism for evaluating whether students maintain these intentions through dental school or implement any of these ideas in later clinic practice. Some students recognized the distance between this early course and their ultimate role as a dentist, put rather aptly by one student: "If I actually ever become a real dentist (and not just a tooth waxer), I will try to always be honest and open with my patients." Future assessments of the long-term outcomes of education in ethics and professionalism should include clarity and consensus within the profession about the goals of education in ethics and professionalism, as well as developing methods to track students’ capacity to apply their knowledge and skills in professional and ethical behavior in clinical settings. Some programs have adopted standardized patient assessment methods for evaluating these skills.22 Although difficult to implement, methods to evaluate the long-term impact of training among dentists after graduation should also be explored.
It is well understood that students acquire professional behaviors and notions of acceptable practices through their interactions and observations with patients, faculty, staff, and fellow students during their training. In medicine, this broader learning has been described as the "hidden curriculum."23 Students have described many ways in which instructors and administrators fail to demonstrate that they value professional or ethical behavior. For example, Dans reported that although instructors are clearly aware of cheating, their lack of response does little to encourage integrity among students.24 Students may observe models of unethical behavior or be asked to comply with unethical acts, such as falsifying documentation, within the educational hierarchy.25 Similarly, students’ perceptions of formal ethics coursework may also be influenced by the perceptions of previous students and by positive or negative comments from faculty members about the value and applicability of ethics courses. Thus, simply offering or adding coursework is not likely to sustain ethical behavior or professionalism among students. Assessment of ethics education should include systematic evaluation of student and faculty attitudes toward ethics courses, and these evaluations should be conducted across programs to achieve generalizability.
Ethics education is an ongoing responsibility of the entire faculty, staff, and administration and cannot be accomplished through the administration of stand-alone lectures, small-group discussions, assignments, or simulations. It is critical that all faculty and staff members are aware of the content of ethics courses so that student learning is reinforced in other contexts. For example, our students occasionally submit a complete ethical analysis of the cases given in their problem-based learning (PBL) curriculum, which is taught separately from ethics coursework. Although PBL facilitators did not expect this response, these instances yielded an excellent opportunity to illustrate the connection between ethics and the broader curriculum. Similar opportunities arise in clinical contexts every day. Faculty supervisors in the clinic must be able to model how to obtain informed consent, accept informed refusal, and discuss how they determined that a patient lacks the capacity to make a dental care decision and the limitations of confidentiality, as well as demonstrating all other aspects of professional behavior. Thus, all those involved with training future dentists are charged with creating a "culture of professionalism" within the curriculum.26–28
The goal of introducing ethics and professionalism to first-year dental students presumably isn’t to achieve the ideal ethical dentist through one course, but rather, to open the students’ minds to the grey areas of practice, to encourage them to consider what it is that defines someone as a "good dentist," and to demonstrate that ethics is relevant to them. Perhaps the value of the current study is to illustrate that, at least in the short term, the majority of freshman dental students perceived ethics "in a vibrant and positive light" (p. 424),4 just as Bertolami hoped they might.
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Acknowledgments
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We thank Rebecca Hague, Devon Van Gessel, and Lindsay Bowman, who assisted with transcription and analyses.
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Author Information
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Dr. Sharp is Assistant Professor, Department of Speech Pathology and Audiology, Western Michigan University and Adjunct Assistant Professor, Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa; Dr. Kuthy is Professor, Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa. Direct correspondence and requests for reprints to Dr. Helen M. Sharp, Department of Speech Pathology and Audiology, Western Michigan University, 1903 West Michigan Ave., Kalamazoo, MI 49008-5355; 269-387-8024 phone; 269-387-8044 fax; Helen.sharp{at}wmich.edu.
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Abstract
Freshman ethics curriculum:...
