A Pragmatic Approach to Professional and Ethical Dilemmas

Setting and Problem

Residency programs are required to educate residents in professionalism and ethics, including teaching residents to identify and resolve ethical dilemmas. Traditionally, the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) educated residents on professionalism/ethics during orientation, using formal didactics followed by case discussions. Resident feedback indicated dissatisfaction with this approach due to lack of follow-up and because the cases did not reflect the day-to-day ethical dilemmas they experienced. Program directors felt that the training was isolated from their own efforts to instill professionalism and ethics. Hospital leadership reported that, despite training, residents had a difficult time recognizing ethical dilemmas, lacked a shared approach, and failed to recognize when official guidance, policies, and laws should be taken into account. The ethics committee noted that resident ethics consults were infrequent and poorly organized.

Intervention

A group consisting of hospital leadership, members of the ethics committee, program directors, residents, and fellows was established to improve the professionalism/ethics program. Tools for resolving ethical dilemmas such as the Ethical Decision-Making Paradigm were available in the literature, but guidance on institutional approaches was less robust. Long-term, organization-wide behavior changes would require developing and deploying a definitive tool or process that would integrate all stakeholders.

The committee designed an “Ethical Dilemma Tool” (provided as online supplemental material) that guided residents through a series of pragmatic steps. Residents are first directed to identify the ethical dilemma, and are then asked to identify the parties involved and determine each party's value system. Where official guidance is available, it is made accessible through relevant documents on the hospital's intranet. When residents cannot identify the ethical dilemma, they are directed to identify the parties and values first and work backward. Residents then work through possible options, weighing the impact to each party; this assists them in the process of selecting a solution.

To improve integration across the hospital, the ethics committee was asked to review the tool to ensure it met expectations for ethics training. Each residency program was asked to train residents on the use of the tool, and to use it as the foundation for an individualized, case-based ethics curriculum.

Outcomes to Date

The tool was piloted on 12 ethical dilemmas encountered by SAUSHEC residents. Feedback indicated that defining the ethical dilemma was easier after completing step 2 of the tool, and that systematically identifying the parties involved in the dilemma was “surprisingly helpful.” One resident noted that the tool directed him to a hospital policy that promptly solved the dilemma. Another noted that once steps 1 and 2 were complete it was “almost redundant” to complete the tool, as the solution was “apparent.”

Formal presentation of the new tool and associated training to the SAUSHEC Graduate Medical Education Committee revealed that 100% of program directors plan to utilize the tool in their ongoing professionalism/ethics education and that they would train residents to utilize the tool prior to the arrival of next year's intern class. The ethics committee changed its policies to indicate that ethics consultations would only be received after the tool had been used. The proposal was presented to the SAUSHEC House Staff Council, a group representative of the residents, and its members were enthusiastic about its utility and practicality.

Conclusions

The tool has also been included in next year's SAUSHEC resident guide, along with abbreviated versions of the online appendices, with the intent that both be used as bedside resources. The tool will also be introduced during resident orientation and practiced on redesigned, prototypical cases, such as consenting for treatment. Additional data, to include course satisfaction rates from incoming residents, ethics committee utilization, interdepartmental communication regarding ethical dilemmas, program director use of the tool within their programs, and ability to demonstrate resident attainment of Milestones related to professionalism and ethics will be monitored as the tool continues to be deployed. If successful, other departments (nursing) and other military hospitals will be offered training in the use of this innovative new approach.