Journal of Perinatology (2015) 35, 875–879 © 2015 Nature America, Inc. All rights reserved 0743-8346/15 www.nature.com/jp
ORIGINAL ARTICLE
Ethics and professionalism education during neonatal–perinatal fellowship training in the United States CL Cummings1, GM Geis2, JC Kesselheim3 and S Sayeed1 OBJECTIVE: The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal–perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues. STUDY DESIGN: Neonatal–Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas. RESULT: Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is ‘important/very important’. Only 63% of Directors and 37% of fellows/graduates rated ethics education as ‘excellent/very good’ (P = 0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P o 0.001). Teaching methods and their perceived effectiveness varied widely. CONCLUSION: Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency. Journal of Perinatology (2015) 35, 875–879; doi:10.1038/jp.2015.70; published online 25 June 2015
INTRODUCTION Medical ethics is highly relevant to the field of neonatology, as neonatologists often care for sick neonates and their families and frequently face difficult situations, including decision-making about resuscitation at the margin of viability and end-of-life care. Adequate training in ethics and professionalism is necessary so that neonatologists may effectively approach and resolve the many ethical dilemmas that arise daily in the neonatal intensive care unit (NICU). Training programs have generally struggled with how to best teach these skills, and several studies have found dissatisfaction among trainees from various specialties about the quality of ethics education.1–6 For example, one study of new pediatricians found that nearly half of them rated the quality of ethics education received during their training as ‘fair or poor’, and many reported limited confidence when confronting various ethically challenging situations common to pediatrics.7 As of 2007, training in ethics and professionalism is a required curriculum component as per the Accreditation Council for Graduate Medical Education for pediatric residents, as well as for neonatal–perinatal fellows (NPFs).8 Following this mandate, a 2009 study concluded that ethics and professionalism education in pediatrics training lacked a ‘structured curriculum, faculty expertise and evaluation methodology’.9 A more recent study suggests that pediatric residency programs have slowly begun to incorporate teaching in ethics and professionalism into their curricula, although this remains largely unstructured and without adequate resident evaluation and assessment of these competencies.10 Similarly, neonatology fellowship programs lack established or standardized curricula in ethics and professionalism. Several authors have attempted to address this need.11–17 Currently, no data document the preparedness of NPFs or early career neonatologists (ECNs) to confidently navigate ethical dilemmas
as they arise in neonatal practice. It is unknown whether current training in ethics is sufficient or how prepared or confident fellows or recently graduated neonatologists feel when challenged with complex ethical situations in the NICU. This study aimed to determine the perceived adequacy of current training in ethics provided to NPFs during their neonatal– perinatal medicine training, and the perceived confidence and comfort level of fellows and ECNs when navigating common ethical situations in the NICU. We evaluated these perceptions by administering two web-based surveys: the first survey to neonatal–perinatal fellowship program directors (PDs) and the second survey to NPFs and ECNs, all in the United States. We hypothesized that (1) PDs, NPFs and ECNs would agree that ethics and professionalism education during fellowship is important, although currently inadequate; (2) NPFs do not feel or are not perceived to be as well prepared to address ethical issues in practice; (3) PDs may perceive their trainees to be more comfortable and facile with ethical issues in the NICU than trainees actually report; and (4) respondents, both PDs and trainees alike, would agree that NPFs would benefit from a standardized, case/simulation-based curriculum in ethics and professionalism. METHODS Study population The target population included NPFs, ECNs and PDs in the United States. ECNs were defined as neonatologists who have graduated from fellowship training within 7 years who are members of the American Academy of Pediatrics (AAP). At the time of this study, there were 97 training programs in neonatal–perinatal medicine, each with an identified PD, as well as 698 NPFs and ECNs who were members of the AAP’s Section on Perinatal Pediatrics group Trainee and Early Career Neonatologist with valid emails.
1 Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA; 2Division of Neonatal-Perinatal Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA and 3Dana-Farber/Boston Children’s Center for Cancer and Blood Disorders, Boston, MA, USA. Correspondence: Dr CL Cummings, Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Hunnewell 437, Boston, MA 02115, USA. E-mail: [email protected] Received 6 January 2015; revised 14 April 2015; accepted 27 May 2015; published online 25 June 2015
Ethics education for neonatologists in training CL Cummings et al
876 Study instrument development and implementation Two similar web-based surveys were developed by the authors via KwikSurveys: one aimed at NPFs and ECNs and the other aimed at PDs in the United States. The surveys were adapted from a survey used in a study of pediatricians’ perceptions of their education in ethics during pediatric residency.8 Questions were revised to reflect differing target populations and ethical milieu specific to neonatology. Four first-year NPFs and four attending neonatologists (who were not PDs) reviewed the survey instruments and participated in cognitive interviewing to ensure face and content validity. Participants were queried on demographics, the amount and type of education in ethics and professionalism provided during training and its perceived effectiveness. Respondents were also asked to evaluate their self-confidence (NPFs/ECNs), or perceived confidence in their trainees (PDs), when confronted with various ethical challenges common to the NICU. Using the AAP’s Section on Perinatal Pediatrics Trainee and Early Career Neonatologist and Organization of Neonatal Training Program Directors current email listservs, the two surveys were sent with permission by link via email in June–July and October 2013 to PDs, and to NPFs/ECNs, respectively, in the United States. The email, which was sent three times to increase the response rate, described the research and invited subjects to participate by completing the voluntary, anonymous online survey using the provided link, which would indicate consent. There was no subject compensation or reimbursement.
Statistical analysis Data from this convenience sample were obtained and recorded without identifiers and analyzed in aggregate form. Frequencies were used to describe respondent characteristics. For analysis and clarity of data presentation, the five response options to questions about confidence when facing ethical challenges were collapsed into three levels (‘not at all confident’ or ‘somewhat confident’; ‘moderately confident’; and ‘confident’ or ‘extremely confident’). Similarly, other five-level response options were collapsed into two or three levels for analysis, including questions rating the importance of ethics education, simulation and communication. Chi-squared tests and Fisher’s exact tests were used where appropriate to compare responses of the PDs and NPF/ECN groups. Bivariate analyses were conducted to determine whether selected variables (sex, age, experience, level of training or the presence of formal training in ethics) were associated with increased confidence when navigating ethical challenges. Here, the five response options to questions about confidence when facing ethical challenges were collapsed into three levels (‘extremely confident’; ‘confident’; and ‘less confident’). Statistical analyses were conducted using SAS 9.3 statistical software (SAS Institute, Cary, NC, USA). Qualitative comments from both surveys were analyzed and categorized by theme by the authors (CLC and GMG).
Research study approval This study was reviewed and approved by the Committee on Clinical Investigation at Boston Children’s Hospital (IRB-P00008327), and was granted exemption from full Institutional Review Board review under federal regulation 45 CFR 46.101(b)(2), including a waiver of written consent. The survey was approved by the AAP’s Section on Perinatal Pediatrics group Trainee and Early Career Neonatologist, which gave authorization for membership distribution.
RESULTS Participants and demographics Forty-six out of 97 neonatal–perinatal fellowship PDs completed the survey, yielding a response rate of 47%. Of the 698 NPFs and ECNs who were emailed, 444 accessed the email and, of those, 82 completed the survey, yielding a response rate of 18%. Baseline characteristics for responding PDs, NPFs and ECNs are shown (Table 1). Over 50% of fellows and recently graduated neonatologists reported anticipated or actual time spent caring for patients to be475%. Of note, 17.4% of PDs and 13.4% of NPFs/ECNs indicated having formal training in medical ethics, which included undergraduate and graduate degrees in ethics or philosophy, educational tracks in ethics during clinical training, a clinical ethics course, a medical ethics fellowship or ‘other’. Journal of Perinatology (2015), 875 – 879
Table 1.
Demographic characteristics PDs n (%)
NPFs/ECNs n (%)
Gender Female Male
20 (43.5) 26 (56.5)
53 (64.6) 29 (35.4)
Formal medical ethics training No Yes Clinical ethics course Medical school track Residency track NPM fellowship track Undergraduate ethics/philosophy Medical ethics fellowship MA ethics/philosophy PhD ethics/philosophy Othera
38 8 6 5 4 4 2 1 0 0 11
71 11 11 3 1 3 1 2 2 0 14
(86.6) (13.4) (13.4) (3.7) (1.2) (3.7) (1.2) (2.4) (2.4) (0.0) (17.1)
0 5 9 21 47
(0.0) (6.1) (11.0) (25.6) (57.3)
Time will be/is spent in patient care (%) 0 1–25 26–50 51–75 475
(82.6) (17.4) (13.0) (10.9) (8.7) (8.7) (4.3) (2.2) (0.0) (0.0) (23.9)
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors. aTotal sums to more than responded ‘yes’, possibly owing to training in progress but not yet completed, as suggested by comments.
Reported use and effectiveness of ethics and professionalism learning methods Nearly 96% of PDs confirmed the inclusion of teaching in ethics during fellowship training, although only 1/3 indicated that this was part of a formal curriculum, vs 71% of NPFs/ECNs (P o0.001). PDs were asked to report the amount of various learning methods used to teach ethics and professionalism during training, whereas NPFs/ECNs were asked to evaluate their perceived effectiveness (Table 2). Commonly reported learning methods included teaching conferences, discussions with other fellows and attendings of individual cases, reading in medical journals, involvement in ethics consultations and discussions with hospital ethicists. The reported use of ethics texts, readings from the lay press, simulations and clinical ethics rotations was minimal to nonexistent, as per PDs. The majority of NPFs/ECNs reported the following learning methods as ‘very effective’ or ‘effective’: teaching conferences, discussions with supervising attendings, reading in medical journals, involvement in ethics consultations and discussions with hospital ethicists. Although few NPFs/ECNs reported participating in ethics simulations or clinical rotations in ethics (35% and 15%, respectively), those who did viewed them favorably, with 66 and 50% reporting these methods as ‘very effective’ or ‘effective’. Quality of education in ethics and professionalism PDs were significantly more likely to rate ethics education provided during training as ‘excellent/very good’ than NPFs or recent graduates (63% vs 37%, P = 0.004) (Table 3). When asked about the level of attention paid by attending neonatologists to ethical dimensions of patient care, 76% of PDs reported this to be ‘excellent’ or ‘very good’, whereas only 51% NPFs/ECNs reported as such (P o 0.001). © 2015 Nature America, Inc.
Ethics education for neonatologists in training CL Cummings et al
877 Table 2.
Reported use and perceived effectiveness of various learning methods in ethics and professionalism during neonatal–perinatal fellowship
Learning method
Reported use (PDs) Major/moderate use
Discussions with supervising attendings Discussions with hospital ethicists Discussions with other fellows Involvement in ethics consultations Teaching conferences Reading in medical journals Simulations Clinical rotation in ethics Reading in ethics texts Reading in the lay press
n 46 31 35 22 41 28 12 4 8 5
Perceived effectiveness (NPFs/ECNs) Very effective/effective
(%) (100.0) (67.3) (76.1) (47.8) (89.1) (60.9) (26.1) (8.7) (17.4) (11.1)
n 74 50 63 47 50 51 19 6 24 24
(%) (91.3) (86.2) (84.0) (82.4) (72.4) (68.0) (65.5) (50.0) (46.2) (36.3)
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors.
Table 3.
Reported quality of ethics and professionalism education during neonatal–perinatal fellowship
Overall rating of ethics education during fellowship Level of attention paid by the attendings to ethical dimensions of patient care
Reported quality (PDs) Excellent/very good
Reported quality (NPFs/ECNs) Excellent/very good
P
n (%) 29 (63.0) 35 (76.1)
n (%) 30 (36.6) 42 (51.2)
0.004 o0.001
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors.
Perceived vs reported confidence when confronting ethical challenges in the NICU Overall, 52% of PDs felt that fellows in their program were ‘very comfortable’ or ‘comfortable’ applying ethical principles to difficult situations in the NICU, whereas 66% of NPFs/ECNs reported that they felt comfortable doing so (P = 0.128). Participants were asked to report perceived confidence when navigating 22 specific challenging ethical situations common to the NICU, and overall confidence (Supplementary Table). Possible answers were ‘not at all confident’, ‘somewhat confident’, ‘moderately confident’, ‘confident’ and ‘extremely confident’, which were collapsed into three categories for analysis. Overall, 83% of PDs felt that fellows in their programs were ‘extremely confident’ or ‘confident’ when navigating ethical dilemmas in the NICU, whereas 76% of NPFs/ECNs reported such confidence (P = 0.518). With respect to the 22 specific ethical challenges, PDs were more likely to rate fellows as ‘extremely confident’ than NPFs/ECNs, who more often reported ‘confident’ (weighted average 3.91 vs 3.71), although this was not statistically significant except in Challenge 11. In this case, when making decisions about life-sustaining therapies for infants with potentially severe neurocognitive disabilities, NPFs/ECNs reported being significantly less confident than perceived by PDs (51% ‘extremely confident/ confident’ vs 80%, respectively, P = 0.004). Ethics and professionalism education and curricula Overall, more than 97% of both PDs and NPFs/ECNs agreed that training in ethics is ‘important’ or ‘very important’ for NPFs (P = 0.924). When asked whether a more standardized educational curriculum for NPFs would be beneficial, over 73% of PDs and 86% of NPFs/ECNs ‘agreed’ or ‘strongly agreed’ (P = 0.073); however, nearly 22% of PDs remained ‘neutral’ and 4% ‘disagreed.’ Sixtyseven percent of PDs and 73% NPFs/ECNs ‘agreed’ or ‘strongly agreed’ that simulation and role-play could be beneficial as part of an ethics curriculum for NPFs (P = 0.489), whereas 26% of PDs © 2015 Nature America, Inc.
remained ‘neutral’ and just over 6% ‘disagreed’ or ‘strongly disagreed.’ Further, 82% of PDs and 85% of NPFs/ECNs felt that more education in communication skills would also be beneficial for fellows (P = 0.68). Bivariate analyses Of the selected several demographic variables (including sex, age, experience, level of training or the presence of formal training in ethics), two were significantly associated with overall reported confidence in the ability to address ethical challenges arising in the NICU: level of training and age. Overall, ECNs reported more confidence (‘extremely confident’) in navigating ethical challenges in practice than fellows (29.5% vs 0% respectively, P o0.001). In addition, the frequency of rating oneself as ‘extremely confident’ overall was directly proportional to age, specifically respondents 440 years old compared with those o 36 years old (42.1% vs 4.9%, respectively, P o 0.001), whereas 36.4% of respondents aged 36 to 40 years old reported as such. Increased respondent age was significantly associated with increased confidence (‘extremely confident’) pertaining to 4 of the 22 ethical challenges, including Challenge 10 (Adolescent Parent Refusal of Treatment; 7.32% vs 21%, P = 0.048), Challenge 14 (Parental Permission for Clinical Trial; 7.3% vs 36.8%, respectively, P = 0.026), Challenge 15 (Parental Permission for Research Procedure; 4.9% vs 31.6%, respectively, P = 0.020) and Challenge 20 (Disclosing Medical Error; 0% vs 26.3%, respectively, P o0.001). However, for Challenge 10 (Adolescent Parent Refusal of Treatment), fewer respondents 440 years old reported being ‘extremely confident’ than those aged 36 to 40 years (21% vs 27.3%, respectively, P = 0.048). Increased level of training (fellows vs ECNs) was also significantly associated with increased confidence (‘extremely confident’) pertaining to four ethical challenges, including Challenge 2 (Difficult Information; 4.8% vs 44.3%, respectively, P o0.001), Challenge 6 (DNR Orders; 4.8% vs 45.9%, respectively, P o0.001), Challenge 7 (Organ Donation; 4.8% vs 29.5%, respectively, Journal of Perinatology (2015), 875 – 879
Ethics education for neonatologists in training CL Cummings et al
878 P = 0.0176) and Challenge 8 (Autopsy; 19% vs 47.5%, respectively, P = 0.0105). Qualitative data Qualitative comments from both surveys were analyzed and categorized by theme by the authors (CLC and GMG). A few respondents expressed concerns about adding further content to an already full training program limited by duty-hour restrictions and other curricular requirements, with one PD pleading ‘no more fellowship course work burdens’. Nevertheless, many responding PDs indicated that, in addition to formal training in ethics and professionalism, a crucial educational component should include active fellow participation and leadership in challenging discussions with families, as well as involvement in ethics consultations. Similarly, NPFs and ECNs overwhelmingly felt that ethics and professionalism is best learned through active participation in difficult discussions with attendings and families, followed by effective trainee feedback. One fellow wrote ‘I would have appreciated more of an effort by attendings to involve the fellows in these difficult situations, rather than leaving them out of the discussion and decision-making process’. Another participant also stressed the importance of ‘discussion between the trainee and the attending’, while adding ‘I don’t think a formal education will be as useful unless this ongoing conversation exists’. The majority of responding NPFs/ENCs felt, as one clearly articulated, that a more ‘structured’ curriculum in ethics and professionalism should be an ‘essential part of fellowship training for future neonatologists’. DISCUSSION Our study revealed several important findings. First, the overwhelming majority of respondents agreed that training in ethics is important for NPFs. Second, few PDs and even fewer NPFs/ECNs rated ethics education as ‘excellent/very good’, highlighting an opportunity for improvement. Third, despite Accreditation Council for Graduate Medical Education requirements, significantly fewer NPFs/ECNs reported teaching in ethics during fellowship training than PDs, raising the possibility of a curricular gap in this area. However, this discrepancy could be because of a lack of trainee recognition that teaching in ethics and professionalism is actually occurring, perhaps as part of an informal curriculum. It is also possible that some training programs have more recently incorporated teaching in ethics, after some of the respondents (ECNs) had graduated, or that more junior NPFs had not yet encountered such teaching if scheduled later in fellowship training. Fourth, there is wide variation in how ethics and professionalism training is being provided to NPFs across the country, as expected given the lack of established guidelines or curriculum specific to neonatology. Although the AAP Bioethics Resident Curriculum and the American Board of Pediatrics guidelines for teaching and assessing professionalism are excellent resources, they are largely aimed at pediatric residents, not neonatology fellows.16,17 Further, they are text-based only and lack hands-on interactive educational learning, which is essential for communication and relational skills. Finally, they also lack appropriate assessment tools in these domains. Educational resources that fulfilled these gaps would potentially be of enormous benefit and value for training programs. Fifth, the learning methods that NPFs/ECNs perceived to be most effective were often aligned with the methods PDs report using most frequently. Perceived effectiveness, however, may not correlate with actual learning, but at least suggests that the method is well received. Relatively few NPFs/ECNs reported participating in ethics simulations or clinical rotations in ethics, although many who did viewed them favorably. Furthermore, the Journal of Perinatology (2015), 875 – 879
majority of respondents ‘agreed’ or ‘strongly agreed’ that simulation and role-play could be beneficial as part of an ethics curriculum for NPFs. Other studies have reported success with using simulation, enacted discussions with standardized actors and role-play to teach professionalism, including communication skills, to medical trainees.18–20 One meta-analysis of ethics education provided to scientists demonstrated that more successful programs were case-based, interactive and allowed participants to learn and practice the application of real-world ethical decision-making skills.21 A group in Canada has recently described a holistic approach to teaching neonatal ethics through the Neonatal Ethics Teaching Program for their neonatal–perinatal medicine residency program.22 The Neonatal Ethics Teaching Program includes education in ethical theory and reasoning, communication skills, learning self-reflection and self-awareness, as well as scenario-oriented learning in ethics.22 Further research is needed to determine optimal learning methods to teach ethics and professionalism to NPFs during fellowship training in the United States. Sixth, most NPFs/ECNs reported being quite confident when approaching an array of challenging ethical situations in the NICU, as was often correctly perceived by PDs. However, NPFs/ECNs reported being significantly less confident than perceived by PDs when making decisions about life-sustaining therapies for infants with potentially severe neurocognitive disabilities. Training programs should use a self-assessment to determine whether their fellows require educational interventions targeting this challenging yet common issue in neonatal practice. Finally, in addition to formal education in ethics and professionalism, qualitative results indicated that increased trainee leadership in ethics discussions and consults with clinical ethicists may be extremely valuable. Respondents also emphasized the importance of timely teaching between trainee and supervising attending regarding ethically challenging cases and family discussions. The American Society for Bioethics and Humanities23 recognizes ethicists as professionals and as educators, crucial to ethics consultation services and the educational mission of hospitals. Integrating clinical ethicists into curriculum development and trainee teaching in neonatology may also be helpful. This study has several limitations, including a NPF/ECN response rate of 18%, with diverse responses within this small convenience sample. Further, selection bias cannot be excluded; those who participated may have different or more strongly held beliefs and attitudes than nonresponders. The listserv used did not distinguish between NPFs and ECNs, and it was discovered to contain two email addresses for neonatologists who had been practicing for 47 years. Reporting and recall biases are possible given the survey format and subjective nature of questions asked. In addition, responses from NPFs and recent graduates were not linked to their training program. In addition, more respondents indicated having received ‘other’ formal training in ethics compared with those who reported ‘yes’ to formal training. This discrepancy is unclear, although it may be that some respondents felt that the education they had received was not considered ‘formal’ or that some were actually in the process of acquiring further training in ethics, and did not feel comfortable responding ‘yes’ when that education had not been completed, as suggested by several comments. Nevertheless, these findings may be helpful in guiding further educational initiatives in these important areas. CONCLUSION There is wide variation in ethics and professionalism training provided to NPFs across the country. The vast majority of PDs, fellows and ECNs felt that training in ethics and professionalism is important, and that a more standardized curriculum would be beneficial, including teaching conferences, simulation and casebased discussions. Respondents also felt that increased informal © 2015 Nature America, Inc.
Ethics education for neonatologists in training CL Cummings et al
879 education, such as trainee participation and leadership in discussions with attendings and families and involvement in ethics consultations, would be beneficial. We speculate that ethicists may be underutilized resources for curriculum development and training in neonatology. Educational efforts should address these curricular gaps to ensure that trainees achieve competency. Further research is needed to determine the most effective methods to teach ethics and professionalism to NPFs, as well as to develop tools to adequately assess competency (both knowledge and behavior skills) in this important domain. Future work could involve linking fellows and recent graduates with their training program to see whether exposure to curricula (as reported by the PDs) affects individual physician confidence and competence, as well as family satisfaction. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We thank Dara Brodsky, MD for her thoughtful review of earlier manuscript drafts, as well as the AAP Section on Perinatal Medicine groups (Trainee and Early Career Neonatologist and Organization of Neonatal Training Program Directors) for help with accessing the respective listerservs and distributing this study. We also thank Peter W. Forbes, MA for assistance with statistical analysis; this work was conducted with statistical support from Harvard Catalyst/The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award 8UL1TR000170-05 and financial contributions from Harvard University and its affiliated academic health care centers). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health. No external funding was secured for this study. The authors have no financial relationships relevant to this article to disclose.
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5 Bolin J. Strategies for incorporating professional ethics education in graduate medical programs. Am J Bioeth 2006; 6: 35–36. 6 de Blacam C, Vercler CJ. Teaching ethics and professionalism in plastic surgery: a systematic review. Ann Plast Surg 2014; 72(4): 484–488. 7 Kesselheim JC, Johnson J, Joffe S. Pediatricians’ reports of their education in ethics. Arch Pediatr Adolesc Med 2008; 162(4): 368–373. 8 Accreditation Council for Graduate Medical Education. General competencies. http:// acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5e_EducationalProgram_ ACGMECompetencies_Professionalism_Explanation.pdf (accessed 30 January 2014). 9 Walsh Lang C, Smith PJ, Friedman Ross L. Ethics and professionalism in the pediatric curriculum: a survey of pediatric program directors. Pediatrics 2009; 124: 1143–1151. 10 Cook AF, Sobotka SA, Ross LF. Teaching and assessment of ethics and professionalism: a survey of pediatric program directors. Acad Pediatr 2013; 13(6): 570–576. 11 Salih Z, Boyle D. Ethics education in neonatal–perinatal medicine in the United States. Semin Perinatol 2009; 33: 397–404. 12 Davis D, Doucet H. A curriculum for teaching clinical ethics in neonatal-perinatal medicine. Ann R Coll Physicians Surg Can 1996; 29: 45–48. 13 Stirrat G. Education in ethics. Clin Perinatol 2003; 30: 1–15. 14 Hellman J. Development of a teaching curriculum in neonatology fellowship training; 2006, http://www.utoronto.ca/pgme/documents/curricula/neonatal_curr2.pdf (accessed 30 January 2014). 15 Daboval T, Moore GP, Rohde K, Moreau K, Ferretti E. Teaching ethics in neonatal and perinatal medicine: what is happening in Canada? Paediatr Child Health 2014; 19(1): e6–e10. 16 Adam MB, Diekema DS, Mercurio MR (eds). American Academy of Pediatrics Bioethics Resident Curriculum: Case-Based Teaching Guides. http://www.aap.org/ sections/bioethics/default.cfm (accessed 3 October 2014). 17 American Board of PediatricsProgram Directors Committee; Association of Pediatric Program Directors. Teaching and Assessing Professionalism: A Program Director’s Guide. American Board of Pediatrics Foundation: Chapel Hill, NC, USA, 2008, www.appd.org/professionalism.pdf (accessed 3 October 2014). 18 Gisondi MA, Smith-Coggins R, Harter PM, Soltysik RC, Yarnold PR. Assessment of resident professionalism using high-fidelity simulation of ethical dilemmas. Acad Emerg Med 2004; 11(9): 931–937. 19 Lamiani G, Meyer EC, Browning DM, Brodsky D. Analysis of enacted difficult conversations in neonatal intensive care. J Perinatol 2009; 29(4); 310–316. 20 Meyer EC, Brodsky D, Hansen AR, Lamiani G, Sellers DE, Browning DM. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol 2010; 31(3): 212–219. 21 Antes AL, Murphy ST, Waples EP, Mumford MD, Brown RP, Connelly S et al. A meta-analysis of ethics instruction effectiveness in the sciences. Ethics Behav 2009; 19(5): 379–402. 22 Daboval T, Ferretti E, Moore GP. Innovative holistic teaching in a Canadian Neonatal Perinatal Medicine Residency Program. Hastings Cent Rep 2014; 44(6): 21–25. 23 American Society for Bioethics and Humanities Clinical Ethics Task Force. Improving Competencies in Clinical Ethics Consultation: An Education Guide. American Society for Bioethics and Humanities: Glenview, 2009.
Supplementary Information accompanies the paper on the Journal of Perinatology website (http://www.nature.com/jp)
© 2015 Nature America, Inc.
Journal of Perinatology (2015), 875 – 879
ORIGINAL ARTICLE
Ethics and professionalism education during neonatal–perinatal fellowship training in the United States CL Cummings1, GM Geis2, JC Kesselheim3 and S Sayeed1 OBJECTIVE: The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal–perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues. STUDY DESIGN: Neonatal–Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas. RESULT: Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is ‘important/very important’. Only 63% of Directors and 37% of fellows/graduates rated ethics education as ‘excellent/very good’ (P = 0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P o 0.001). Teaching methods and their perceived effectiveness varied widely. CONCLUSION: Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency. Journal of Perinatology (2015) 35, 875–879; doi:10.1038/jp.2015.70; published online 25 June 2015
INTRODUCTION Medical ethics is highly relevant to the field of neonatology, as neonatologists often care for sick neonates and their families and frequently face difficult situations, including decision-making about resuscitation at the margin of viability and end-of-life care. Adequate training in ethics and professionalism is necessary so that neonatologists may effectively approach and resolve the many ethical dilemmas that arise daily in the neonatal intensive care unit (NICU). Training programs have generally struggled with how to best teach these skills, and several studies have found dissatisfaction among trainees from various specialties about the quality of ethics education.1–6 For example, one study of new pediatricians found that nearly half of them rated the quality of ethics education received during their training as ‘fair or poor’, and many reported limited confidence when confronting various ethically challenging situations common to pediatrics.7 As of 2007, training in ethics and professionalism is a required curriculum component as per the Accreditation Council for Graduate Medical Education for pediatric residents, as well as for neonatal–perinatal fellows (NPFs).8 Following this mandate, a 2009 study concluded that ethics and professionalism education in pediatrics training lacked a ‘structured curriculum, faculty expertise and evaluation methodology’.9 A more recent study suggests that pediatric residency programs have slowly begun to incorporate teaching in ethics and professionalism into their curricula, although this remains largely unstructured and without adequate resident evaluation and assessment of these competencies.10 Similarly, neonatology fellowship programs lack established or standardized curricula in ethics and professionalism. Several authors have attempted to address this need.11–17 Currently, no data document the preparedness of NPFs or early career neonatologists (ECNs) to confidently navigate ethical dilemmas
as they arise in neonatal practice. It is unknown whether current training in ethics is sufficient or how prepared or confident fellows or recently graduated neonatologists feel when challenged with complex ethical situations in the NICU. This study aimed to determine the perceived adequacy of current training in ethics provided to NPFs during their neonatal– perinatal medicine training, and the perceived confidence and comfort level of fellows and ECNs when navigating common ethical situations in the NICU. We evaluated these perceptions by administering two web-based surveys: the first survey to neonatal–perinatal fellowship program directors (PDs) and the second survey to NPFs and ECNs, all in the United States. We hypothesized that (1) PDs, NPFs and ECNs would agree that ethics and professionalism education during fellowship is important, although currently inadequate; (2) NPFs do not feel or are not perceived to be as well prepared to address ethical issues in practice; (3) PDs may perceive their trainees to be more comfortable and facile with ethical issues in the NICU than trainees actually report; and (4) respondents, both PDs and trainees alike, would agree that NPFs would benefit from a standardized, case/simulation-based curriculum in ethics and professionalism. METHODS Study population The target population included NPFs, ECNs and PDs in the United States. ECNs were defined as neonatologists who have graduated from fellowship training within 7 years who are members of the American Academy of Pediatrics (AAP). At the time of this study, there were 97 training programs in neonatal–perinatal medicine, each with an identified PD, as well as 698 NPFs and ECNs who were members of the AAP’s Section on Perinatal Pediatrics group Trainee and Early Career Neonatologist with valid emails.
1 Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA; 2Division of Neonatal-Perinatal Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA and 3Dana-Farber/Boston Children’s Center for Cancer and Blood Disorders, Boston, MA, USA. Correspondence: Dr CL Cummings, Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Hunnewell 437, Boston, MA 02115, USA. E-mail: [email protected] Received 6 January 2015; revised 14 April 2015; accepted 27 May 2015; published online 25 June 2015
Ethics education for neonatologists in training CL Cummings et al
876 Study instrument development and implementation Two similar web-based surveys were developed by the authors via KwikSurveys: one aimed at NPFs and ECNs and the other aimed at PDs in the United States. The surveys were adapted from a survey used in a study of pediatricians’ perceptions of their education in ethics during pediatric residency.8 Questions were revised to reflect differing target populations and ethical milieu specific to neonatology. Four first-year NPFs and four attending neonatologists (who were not PDs) reviewed the survey instruments and participated in cognitive interviewing to ensure face and content validity. Participants were queried on demographics, the amount and type of education in ethics and professionalism provided during training and its perceived effectiveness. Respondents were also asked to evaluate their self-confidence (NPFs/ECNs), or perceived confidence in their trainees (PDs), when confronted with various ethical challenges common to the NICU. Using the AAP’s Section on Perinatal Pediatrics Trainee and Early Career Neonatologist and Organization of Neonatal Training Program Directors current email listservs, the two surveys were sent with permission by link via email in June–July and October 2013 to PDs, and to NPFs/ECNs, respectively, in the United States. The email, which was sent three times to increase the response rate, described the research and invited subjects to participate by completing the voluntary, anonymous online survey using the provided link, which would indicate consent. There was no subject compensation or reimbursement.
Statistical analysis Data from this convenience sample were obtained and recorded without identifiers and analyzed in aggregate form. Frequencies were used to describe respondent characteristics. For analysis and clarity of data presentation, the five response options to questions about confidence when facing ethical challenges were collapsed into three levels (‘not at all confident’ or ‘somewhat confident’; ‘moderately confident’; and ‘confident’ or ‘extremely confident’). Similarly, other five-level response options were collapsed into two or three levels for analysis, including questions rating the importance of ethics education, simulation and communication. Chi-squared tests and Fisher’s exact tests were used where appropriate to compare responses of the PDs and NPF/ECN groups. Bivariate analyses were conducted to determine whether selected variables (sex, age, experience, level of training or the presence of formal training in ethics) were associated with increased confidence when navigating ethical challenges. Here, the five response options to questions about confidence when facing ethical challenges were collapsed into three levels (‘extremely confident’; ‘confident’; and ‘less confident’). Statistical analyses were conducted using SAS 9.3 statistical software (SAS Institute, Cary, NC, USA). Qualitative comments from both surveys were analyzed and categorized by theme by the authors (CLC and GMG).
Research study approval This study was reviewed and approved by the Committee on Clinical Investigation at Boston Children’s Hospital (IRB-P00008327), and was granted exemption from full Institutional Review Board review under federal regulation 45 CFR 46.101(b)(2), including a waiver of written consent. The survey was approved by the AAP’s Section on Perinatal Pediatrics group Trainee and Early Career Neonatologist, which gave authorization for membership distribution.
RESULTS Participants and demographics Forty-six out of 97 neonatal–perinatal fellowship PDs completed the survey, yielding a response rate of 47%. Of the 698 NPFs and ECNs who were emailed, 444 accessed the email and, of those, 82 completed the survey, yielding a response rate of 18%. Baseline characteristics for responding PDs, NPFs and ECNs are shown (Table 1). Over 50% of fellows and recently graduated neonatologists reported anticipated or actual time spent caring for patients to be475%. Of note, 17.4% of PDs and 13.4% of NPFs/ECNs indicated having formal training in medical ethics, which included undergraduate and graduate degrees in ethics or philosophy, educational tracks in ethics during clinical training, a clinical ethics course, a medical ethics fellowship or ‘other’. Journal of Perinatology (2015), 875 – 879
Table 1.
Demographic characteristics PDs n (%)
NPFs/ECNs n (%)
Gender Female Male
20 (43.5) 26 (56.5)
53 (64.6) 29 (35.4)
Formal medical ethics training No Yes Clinical ethics course Medical school track Residency track NPM fellowship track Undergraduate ethics/philosophy Medical ethics fellowship MA ethics/philosophy PhD ethics/philosophy Othera
38 8 6 5 4 4 2 1 0 0 11
71 11 11 3 1 3 1 2 2 0 14
(86.6) (13.4) (13.4) (3.7) (1.2) (3.7) (1.2) (2.4) (2.4) (0.0) (17.1)
0 5 9 21 47
(0.0) (6.1) (11.0) (25.6) (57.3)
Time will be/is spent in patient care (%) 0 1–25 26–50 51–75 475
(82.6) (17.4) (13.0) (10.9) (8.7) (8.7) (4.3) (2.2) (0.0) (0.0) (23.9)
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors. aTotal sums to more than responded ‘yes’, possibly owing to training in progress but not yet completed, as suggested by comments.
Reported use and effectiveness of ethics and professionalism learning methods Nearly 96% of PDs confirmed the inclusion of teaching in ethics during fellowship training, although only 1/3 indicated that this was part of a formal curriculum, vs 71% of NPFs/ECNs (P o0.001). PDs were asked to report the amount of various learning methods used to teach ethics and professionalism during training, whereas NPFs/ECNs were asked to evaluate their perceived effectiveness (Table 2). Commonly reported learning methods included teaching conferences, discussions with other fellows and attendings of individual cases, reading in medical journals, involvement in ethics consultations and discussions with hospital ethicists. The reported use of ethics texts, readings from the lay press, simulations and clinical ethics rotations was minimal to nonexistent, as per PDs. The majority of NPFs/ECNs reported the following learning methods as ‘very effective’ or ‘effective’: teaching conferences, discussions with supervising attendings, reading in medical journals, involvement in ethics consultations and discussions with hospital ethicists. Although few NPFs/ECNs reported participating in ethics simulations or clinical rotations in ethics (35% and 15%, respectively), those who did viewed them favorably, with 66 and 50% reporting these methods as ‘very effective’ or ‘effective’. Quality of education in ethics and professionalism PDs were significantly more likely to rate ethics education provided during training as ‘excellent/very good’ than NPFs or recent graduates (63% vs 37%, P = 0.004) (Table 3). When asked about the level of attention paid by attending neonatologists to ethical dimensions of patient care, 76% of PDs reported this to be ‘excellent’ or ‘very good’, whereas only 51% NPFs/ECNs reported as such (P o 0.001). © 2015 Nature America, Inc.
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877 Table 2.
Reported use and perceived effectiveness of various learning methods in ethics and professionalism during neonatal–perinatal fellowship
Learning method
Reported use (PDs) Major/moderate use
Discussions with supervising attendings Discussions with hospital ethicists Discussions with other fellows Involvement in ethics consultations Teaching conferences Reading in medical journals Simulations Clinical rotation in ethics Reading in ethics texts Reading in the lay press
n 46 31 35 22 41 28 12 4 8 5
Perceived effectiveness (NPFs/ECNs) Very effective/effective
(%) (100.0) (67.3) (76.1) (47.8) (89.1) (60.9) (26.1) (8.7) (17.4) (11.1)
n 74 50 63 47 50 51 19 6 24 24
(%) (91.3) (86.2) (84.0) (82.4) (72.4) (68.0) (65.5) (50.0) (46.2) (36.3)
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors.
Table 3.
Reported quality of ethics and professionalism education during neonatal–perinatal fellowship
Overall rating of ethics education during fellowship Level of attention paid by the attendings to ethical dimensions of patient care
Reported quality (PDs) Excellent/very good
Reported quality (NPFs/ECNs) Excellent/very good
P
n (%) 29 (63.0) 35 (76.1)
n (%) 30 (36.6) 42 (51.2)
0.004 o0.001
Abbreviations: ECNs, early career neonatologists; NPFs, neonatal–perinatal fellows; PDs, program directors.
Perceived vs reported confidence when confronting ethical challenges in the NICU Overall, 52% of PDs felt that fellows in their program were ‘very comfortable’ or ‘comfortable’ applying ethical principles to difficult situations in the NICU, whereas 66% of NPFs/ECNs reported that they felt comfortable doing so (P = 0.128). Participants were asked to report perceived confidence when navigating 22 specific challenging ethical situations common to the NICU, and overall confidence (Supplementary Table). Possible answers were ‘not at all confident’, ‘somewhat confident’, ‘moderately confident’, ‘confident’ and ‘extremely confident’, which were collapsed into three categories for analysis. Overall, 83% of PDs felt that fellows in their programs were ‘extremely confident’ or ‘confident’ when navigating ethical dilemmas in the NICU, whereas 76% of NPFs/ECNs reported such confidence (P = 0.518). With respect to the 22 specific ethical challenges, PDs were more likely to rate fellows as ‘extremely confident’ than NPFs/ECNs, who more often reported ‘confident’ (weighted average 3.91 vs 3.71), although this was not statistically significant except in Challenge 11. In this case, when making decisions about life-sustaining therapies for infants with potentially severe neurocognitive disabilities, NPFs/ECNs reported being significantly less confident than perceived by PDs (51% ‘extremely confident/ confident’ vs 80%, respectively, P = 0.004). Ethics and professionalism education and curricula Overall, more than 97% of both PDs and NPFs/ECNs agreed that training in ethics is ‘important’ or ‘very important’ for NPFs (P = 0.924). When asked whether a more standardized educational curriculum for NPFs would be beneficial, over 73% of PDs and 86% of NPFs/ECNs ‘agreed’ or ‘strongly agreed’ (P = 0.073); however, nearly 22% of PDs remained ‘neutral’ and 4% ‘disagreed.’ Sixtyseven percent of PDs and 73% NPFs/ECNs ‘agreed’ or ‘strongly agreed’ that simulation and role-play could be beneficial as part of an ethics curriculum for NPFs (P = 0.489), whereas 26% of PDs © 2015 Nature America, Inc.
remained ‘neutral’ and just over 6% ‘disagreed’ or ‘strongly disagreed.’ Further, 82% of PDs and 85% of NPFs/ECNs felt that more education in communication skills would also be beneficial for fellows (P = 0.68). Bivariate analyses Of the selected several demographic variables (including sex, age, experience, level of training or the presence of formal training in ethics), two were significantly associated with overall reported confidence in the ability to address ethical challenges arising in the NICU: level of training and age. Overall, ECNs reported more confidence (‘extremely confident’) in navigating ethical challenges in practice than fellows (29.5% vs 0% respectively, P o0.001). In addition, the frequency of rating oneself as ‘extremely confident’ overall was directly proportional to age, specifically respondents 440 years old compared with those o 36 years old (42.1% vs 4.9%, respectively, P o 0.001), whereas 36.4% of respondents aged 36 to 40 years old reported as such. Increased respondent age was significantly associated with increased confidence (‘extremely confident’) pertaining to 4 of the 22 ethical challenges, including Challenge 10 (Adolescent Parent Refusal of Treatment; 7.32% vs 21%, P = 0.048), Challenge 14 (Parental Permission for Clinical Trial; 7.3% vs 36.8%, respectively, P = 0.026), Challenge 15 (Parental Permission for Research Procedure; 4.9% vs 31.6%, respectively, P = 0.020) and Challenge 20 (Disclosing Medical Error; 0% vs 26.3%, respectively, P o0.001). However, for Challenge 10 (Adolescent Parent Refusal of Treatment), fewer respondents 440 years old reported being ‘extremely confident’ than those aged 36 to 40 years (21% vs 27.3%, respectively, P = 0.048). Increased level of training (fellows vs ECNs) was also significantly associated with increased confidence (‘extremely confident’) pertaining to four ethical challenges, including Challenge 2 (Difficult Information; 4.8% vs 44.3%, respectively, P o0.001), Challenge 6 (DNR Orders; 4.8% vs 45.9%, respectively, P o0.001), Challenge 7 (Organ Donation; 4.8% vs 29.5%, respectively, Journal of Perinatology (2015), 875 – 879
Ethics education for neonatologists in training CL Cummings et al
878 P = 0.0176) and Challenge 8 (Autopsy; 19% vs 47.5%, respectively, P = 0.0105). Qualitative data Qualitative comments from both surveys were analyzed and categorized by theme by the authors (CLC and GMG). A few respondents expressed concerns about adding further content to an already full training program limited by duty-hour restrictions and other curricular requirements, with one PD pleading ‘no more fellowship course work burdens’. Nevertheless, many responding PDs indicated that, in addition to formal training in ethics and professionalism, a crucial educational component should include active fellow participation and leadership in challenging discussions with families, as well as involvement in ethics consultations. Similarly, NPFs and ECNs overwhelmingly felt that ethics and professionalism is best learned through active participation in difficult discussions with attendings and families, followed by effective trainee feedback. One fellow wrote ‘I would have appreciated more of an effort by attendings to involve the fellows in these difficult situations, rather than leaving them out of the discussion and decision-making process’. Another participant also stressed the importance of ‘discussion between the trainee and the attending’, while adding ‘I don’t think a formal education will be as useful unless this ongoing conversation exists’. The majority of responding NPFs/ENCs felt, as one clearly articulated, that a more ‘structured’ curriculum in ethics and professionalism should be an ‘essential part of fellowship training for future neonatologists’. DISCUSSION Our study revealed several important findings. First, the overwhelming majority of respondents agreed that training in ethics is important for NPFs. Second, few PDs and even fewer NPFs/ECNs rated ethics education as ‘excellent/very good’, highlighting an opportunity for improvement. Third, despite Accreditation Council for Graduate Medical Education requirements, significantly fewer NPFs/ECNs reported teaching in ethics during fellowship training than PDs, raising the possibility of a curricular gap in this area. However, this discrepancy could be because of a lack of trainee recognition that teaching in ethics and professionalism is actually occurring, perhaps as part of an informal curriculum. It is also possible that some training programs have more recently incorporated teaching in ethics, after some of the respondents (ECNs) had graduated, or that more junior NPFs had not yet encountered such teaching if scheduled later in fellowship training. Fourth, there is wide variation in how ethics and professionalism training is being provided to NPFs across the country, as expected given the lack of established guidelines or curriculum specific to neonatology. Although the AAP Bioethics Resident Curriculum and the American Board of Pediatrics guidelines for teaching and assessing professionalism are excellent resources, they are largely aimed at pediatric residents, not neonatology fellows.16,17 Further, they are text-based only and lack hands-on interactive educational learning, which is essential for communication and relational skills. Finally, they also lack appropriate assessment tools in these domains. Educational resources that fulfilled these gaps would potentially be of enormous benefit and value for training programs. Fifth, the learning methods that NPFs/ECNs perceived to be most effective were often aligned with the methods PDs report using most frequently. Perceived effectiveness, however, may not correlate with actual learning, but at least suggests that the method is well received. Relatively few NPFs/ECNs reported participating in ethics simulations or clinical rotations in ethics, although many who did viewed them favorably. Furthermore, the Journal of Perinatology (2015), 875 – 879
majority of respondents ‘agreed’ or ‘strongly agreed’ that simulation and role-play could be beneficial as part of an ethics curriculum for NPFs. Other studies have reported success with using simulation, enacted discussions with standardized actors and role-play to teach professionalism, including communication skills, to medical trainees.18–20 One meta-analysis of ethics education provided to scientists demonstrated that more successful programs were case-based, interactive and allowed participants to learn and practice the application of real-world ethical decision-making skills.21 A group in Canada has recently described a holistic approach to teaching neonatal ethics through the Neonatal Ethics Teaching Program for their neonatal–perinatal medicine residency program.22 The Neonatal Ethics Teaching Program includes education in ethical theory and reasoning, communication skills, learning self-reflection and self-awareness, as well as scenario-oriented learning in ethics.22 Further research is needed to determine optimal learning methods to teach ethics and professionalism to NPFs during fellowship training in the United States. Sixth, most NPFs/ECNs reported being quite confident when approaching an array of challenging ethical situations in the NICU, as was often correctly perceived by PDs. However, NPFs/ECNs reported being significantly less confident than perceived by PDs when making decisions about life-sustaining therapies for infants with potentially severe neurocognitive disabilities. Training programs should use a self-assessment to determine whether their fellows require educational interventions targeting this challenging yet common issue in neonatal practice. Finally, in addition to formal education in ethics and professionalism, qualitative results indicated that increased trainee leadership in ethics discussions and consults with clinical ethicists may be extremely valuable. Respondents also emphasized the importance of timely teaching between trainee and supervising attending regarding ethically challenging cases and family discussions. The American Society for Bioethics and Humanities23 recognizes ethicists as professionals and as educators, crucial to ethics consultation services and the educational mission of hospitals. Integrating clinical ethicists into curriculum development and trainee teaching in neonatology may also be helpful. This study has several limitations, including a NPF/ECN response rate of 18%, with diverse responses within this small convenience sample. Further, selection bias cannot be excluded; those who participated may have different or more strongly held beliefs and attitudes than nonresponders. The listserv used did not distinguish between NPFs and ECNs, and it was discovered to contain two email addresses for neonatologists who had been practicing for 47 years. Reporting and recall biases are possible given the survey format and subjective nature of questions asked. In addition, responses from NPFs and recent graduates were not linked to their training program. In addition, more respondents indicated having received ‘other’ formal training in ethics compared with those who reported ‘yes’ to formal training. This discrepancy is unclear, although it may be that some respondents felt that the education they had received was not considered ‘formal’ or that some were actually in the process of acquiring further training in ethics, and did not feel comfortable responding ‘yes’ when that education had not been completed, as suggested by several comments. Nevertheless, these findings may be helpful in guiding further educational initiatives in these important areas. CONCLUSION There is wide variation in ethics and professionalism training provided to NPFs across the country. The vast majority of PDs, fellows and ECNs felt that training in ethics and professionalism is important, and that a more standardized curriculum would be beneficial, including teaching conferences, simulation and casebased discussions. Respondents also felt that increased informal © 2015 Nature America, Inc.
Ethics education for neonatologists in training CL Cummings et al
879 education, such as trainee participation and leadership in discussions with attendings and families and involvement in ethics consultations, would be beneficial. We speculate that ethicists may be underutilized resources for curriculum development and training in neonatology. Educational efforts should address these curricular gaps to ensure that trainees achieve competency. Further research is needed to determine the most effective methods to teach ethics and professionalism to NPFs, as well as to develop tools to adequately assess competency (both knowledge and behavior skills) in this important domain. Future work could involve linking fellows and recent graduates with their training program to see whether exposure to curricula (as reported by the PDs) affects individual physician confidence and competence, as well as family satisfaction. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We thank Dara Brodsky, MD for her thoughtful review of earlier manuscript drafts, as well as the AAP Section on Perinatal Medicine groups (Trainee and Early Career Neonatologist and Organization of Neonatal Training Program Directors) for help with accessing the respective listerservs and distributing this study. We also thank Peter W. Forbes, MA for assistance with statistical analysis; this work was conducted with statistical support from Harvard Catalyst/The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award 8UL1TR000170-05 and financial contributions from Harvard University and its affiliated academic health care centers). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health. No external funding was secured for this study. The authors have no financial relationships relevant to this article to disclose.
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Supplementary Information accompanies the paper on the Journal of Perinatology website (http://www.nature.com/jp)
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Journal of Perinatology (2015), 875 – 879
