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Available online at www.sciencedirect.com
Seminars in Perinatology www.seminperinat.com
Teaching and assessing ethics in the newborn ICU Christy L. Cummings, MD Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Hunnewell 437, Boston, MA
article info
abstra ct
Keywords:
Ethics and professionalism education has become increasingly recognized as important
Ethics
and incorporated into graduate medical education. However, such education has remained
Professionalism
largely unstructured and understudied in neonatology. Neonatal–perinatal fellowship
Communication
training programs have generally grappled with how best to teach and assess ethics and
Graduate medical education
professionalism knowledge, skills, and behavior in clinical practice, particularly in light of
Training
accreditation requirements, milestones, and competencies. This article reviews currently
Neonatology
available teaching methods, pedagogy, and resources in medical ethics, professionalism,
Assessment
and communication, as well as assessment strategies and tools, to help medical educators
Milestones
and practicing clinicians ensure trainees achieve and maintain competency. The need for
Competency
consensus and future research in these domains is also highlighted.
Entrustable professional activity
Introduction Ethics and professionalism education has become increasingly recognized as important for the development of a physician capable of moral introspection and effective navigation of ethical dilemmas and challenging situations in clinical practice. Teaching focused on ethics and professionalism has been incorporated into both medical school and graduate medical education.1–7 Such education, however, has remained largely unstructured and understudied in neonatology.8–12 Neonatal–perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies set forth by the Accreditation Council for Graduate Medical Education (ACGME)13 and the American Board of Pediatrics (ABP) via the Milestones Project.14–17 A recent national study by our group showed that participating neonatal–perinatal fellows and recent graduates were dissatisfied with their training in ethics education, and significantly less likely to rate the ethics education
& 2016 Elsevier Inc. All rights reserved.
provided during fellowship as “excellent/very good” than program directors (37% vs. 63%, p ¼ 0.004).18 Although over 97% of respondents agreed that ethics training is “important/very important,” and 96% of program directors reported the inclusion of ethics education for fellows, only 70% of fellows and recent graduates reported such teaching (p o 0.001), signaling a continued need for curricular improvement in this area.18 This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency in neonatology. Finally, the need for consensus and future research in these domains is also highlighted.
Ethics and professionalism goals and objectives Studies have shown that most students arrive at medical school with well-established ethical and moral perspectives.2
The author is grateful for support from the Division of Newborn Medicine at Boston Children’s Hospital, Boston, MA. This work is supported in part by a grant from the Arnold P. Gold Foundation (grant Id no. FI-15-005), United States. E-mail address: [email protected] http://dx.doi.org/10.1053/j.semperi.2015.12.016 0146-0005/& 2016 Elsevier Inc. All rights reserved.
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By the time trainees arrive at neonatology fellowship, many will have taken some form of ethics class or course. The goal of medical ethics education in neonatology is, thus, to further augment and refine existing ethics knowledge, and skills, while also introducing novel concepts and frameworks specific to the field of neonatology, in order to develop virtuous neonatologists with the necessary skills to effectively and compassionately recognize, analyze and resolve ethical dilemmas in the neonatal intensive care unit (NICU).2 The goal is to teach trainees in neonatal–perinatal medicine to move beyond a simplistic mastery of ethics principles, to develop adaptive expertise such that they are able to creatively and flexibly extend existing knowledge and skills to novel or unexpected ethical situations in practice. Many of these skills and behaviors are deemed to be essential by accreditation organizations, such as the ACGME and the ABP, for graduation from neonatal–perinatal fellowship training programs.13–17,19,20
Competencies, milestones, and entrustable professional activities (EPAs) Every pediatric subspecialty trainee, including neonatal–perinatal medicine fellows, must demonstrate (1) competency along 6 broad domains (patient care ¼ PC, medical knowledge ¼ MK, practice-based learning and improvement ¼ PBLI, interpersonal and communication skills ¼ IPCS, personal and professional development ¼ PPD, and systems-based practice ¼ SBP), (2) adequate progression along meaningful milestones within each domain relevant to clinical practice, and (3) the ability to perform designated entrustable professional activities (EPAs) effectively and without supervision.14–17 Competencies may be viewed as knowledge or skill, while EPAs are essential tasks in clinical practice that can be observed in a discreet time frame.17 To successfully perform an EPA, a learner must not only have mastered single competencies, but must have the ability to autonomously integrate them together.17 Many neonatal–perinatal training programs and their associated Clinical Competency Committees (CCC) have largely struggled with how best to link competencies, milestones, and EPAs, particularly those related to ethics and professionalism, which overlap and may be more difficult to define and assess.17,19,20 Table 1 modified from the work of ten Cate and Scheele,17 Council of Pediatric Subspecialties (CoPS),19 and Organization of Neonatal Training Program Directors (ONTPD),20 summarizes EPAs, selected milestones and competencies relevant to ethics and professionalism in neonatology.13–16
Teaching ethics and professionalism Pedagogy and teaching methods Adult learning theory states that learners learn best when education is self-directed, goal oriented and practical, built on life experiences (experiential learning), and existing frameworks.21,22 Knowledge results from a continuous cycle of grasping and transforming these experiences, through
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concrete experience, abstract conceptualization, reflective observation, and active experimentation.22 Further, adult learners learn best when given their preferred learning method, which complements their learning style. A summary of 4 learning styles, described by Kolb, is outlined in Table 2, along with associated characteristics and preferred learning methods.21,22 Note, however, that an individual learner is likely to be a combination of styles; preferred learning methods may vary. Thus, a variety of teaching methods, woven into a hybrid curriculum, is more likely to effectively teach knowledge and skills to a group of adult learners. A variety of teaching methods may be used to teach ethics and professionalism in neonatology (Table 4). Neonatal– perinatal fellows and recent graduates reported in our study several learning methods to be more effective than others, specifically discussions with supervising attendings, hospital ethicists and peers, involvement in family meetings and ethics consultations, teaching conferences, assigned reading in medical journals, and simulation.18 While perceived effectiveness may not always correlate with actual learning, these results suggested that those methods in ethics education were well received. We also found that in addition to formal training in ethics education, increased trainee leadership in ethics discussions and consults with supervising attendings and clinical ethicists was desired by fellows and may be extremely valuable.18 Such facilitated observation and feedback in clinical practice can be particularly effective in teaching ethics and professionalism. Physician–educators and clinical faculty should serve as role models to continue to inspire subsequent generations of neonatologists to be virtuous, compassionate clinicians adept at navigating modern ethical challenges in the NICU. Several studies have found that small group discussions of ethics to be significantly more effective than lecture courses in developing moral reasoning skills.2 Numerous studies have also shown that thoughtful and strategic use of video in medical education can be a powerful and effective teaching and learning tool.23–25 Videos can quickly relay key concepts, particularly those that are more abstract such as ethics and professionalism, while reaching learners with various preferred learning and communication styles.23 When skillfully integrated into a lecture class or group discussion, the use of video can: (1) “Present more information in a given amount of space and time. (2) Simplify complex concepts. (3) Clarify pieces of abstract language-based concepts (4) Demonstrate concepts/subjects that are in motion and/or relate to one another. (5) Be more efficient and effective at getting audience attention.”23
When incorporating video clips into sessions, one must be cognizant of copyright considerations. The fair use statute allows for appropriate use of copyrighted material (including video) without permission, provided that the use is socially useful, such as scholarship or research, and meets other
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Table 1 – Entrustable Professional Activities (EPAs) and selected milestones mapped to competencies relevant to ethics and professionalism in neonatology.a Entrustable professional activity (EPA)b
Selected milestones (relevant to ethics and professionalism in neonatology)
Competency
(1) Apply public health principles and improvement methodology to improve the health of populations, communities, and systems
Collaborate with others to improve systems of neonatal care Recognize one’s professional responsibility to populations, communities, and society Utilize risk-benefit and cost-benefit analysis Engage actively in the stewardship of resources in the NICU
PBLI 4,7 SBP 3–7 PPD
(2) Provide for and obtain consultation from other health care providers caring for children
Communicate key information when engaging another consultant Help families in the NICU, deal with uncertainty in the diagnosis or prognosis that requires engagement of the consultant
PC 6 PBLI 1 ICS 3–5 SBP 2 PPD 8
(3) Contribute to the fiscally sound and ethical management of a practice (through billing, scheduling, coding, and record keeping practices)
Billing (accurately, honestly, and compliant) Document accurately and honestly to serve the needs of the patient and comply with regulatory requirements Provide care with attention to cost-benefit analyses
SBP 1– 6PPD
(4) Facilitate handovers to another health care provider
Engage in bidirectional communication of plans and expectations with families and caregivers Provide feedback to individual initiating handover of any errors that occurred, including inaccurate information transmission
ICS 3,6 PBLI 5,7
(5) Lead and work within interprofessional health care teams
Elicit and value perspective and contributions of others on team Balance autonomy and appropriate supervision of team members Recognize and manage social cues, emotional responses, and personal/professional needs of team members Role modeling
PBLI 8,9 ICS 2,4 SBP 5 PPD 4,6
(6) Engage in scholarly activities through the discovery, application, and dissemination of new knowledge
Critical analysis of one’s own work as well as work of others Conduct high-quality research Demonstrate ethical principles and practices in conducting scholarly activities and research
PBLI 2–9 ICS PPD
(7) Lead within the subspecialty profession
Advocate for issues in neonatal–perinatal medicine, recognizing vulnerabilities unique to this population (eg., infants, premature infants at the limits of viability, infants with congenital anomalies or neurologic injury/ deficits)
ICS 1,4 SBP 4,7 PPD 4,6
(8) Management of neonatal care systems
Prioritize deployment of resources to those with highest acuity or needs Develop a utilization plan that incorporates prioritized needs of individual patients, the composition and capabilities of personnel with environment (NICU, transport, OR, DR, etc), and the needs of the parents and family Recognize limits and ask for help Communicate utilization and deployment plans to personnel in succinct and timely manner
PC 2 SBP 2, 5PPD 6
(9) Manage patients with complex, multisystem diseases in the NICU
Coordinate inter-disciplinary care of the complex neonate, including reconciling disparate opinions from other health care professionals, parents, and family Manage uncertainties at the personal, team, and family level (eg., Is there sufficient evidence to offer and/or recommend this treatment option to the family? Are we doing the right thing?) Lead a complicated family discussion (DNR or WLST) Convey bad news (including undesired results and poor prognosis) and disclosing medical error or lifethreatening complications
PC 9 MK 2 PBLI 1,6 SBP 2 ICS 4 PPD 8 PROF 5,6,8
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Table 1 (continued) ) Entrustable professional activity (EPA)b
Selected milestones (relevant to ethics and professionalism in neonatology)
Competency
Identify key ethical principles used in decision-making and apply them to common ethical scenarios in neonatology Provide compassionate medical care and empathetic support to critically ill infants near the end of life, and their families Maintain high standards of ethical behavior, including maintaining appropriate professional boundaries Establish trust that makes colleagues feel secure when one is responsible for the care of patients (10) Provide care to patients in the NICU with surgical problems in collaboration with pediatric and subspecialty surgeons
Recognize conditions where surgery is indicated, including knowledge of one’s own limitations of one’s ability to manage problems medically Communicate directly with pediatric/subspecialty surgeon to facilitate timely and coordinated care of neonates with surgical needs Provide continuity of care that insures parents and families understand diagnosis, prognosis, and uncertainties
ICS 3,5 SBP 2 PPD 1,2
(11) Provide resuscitation and stabilization of neonates and infants, which aligns care with severity of illness
Anticipate and recognize the sick infant requiring resuscitation, including effective antenatal counseling and counseling after delivery Effectively lead an interprofessional team before, during, and after a resuscitation, including the ability to reflect on one’s own behaviors and provide effective feedback to team
PC 13 ICS 2 PPD 6,7 SBP 5
(12) Manage patients with acute, common single-system diseases in an inpatient setting
Place the patient at the center of all management decisions to provide patient- and family-centered care by engaging in bidirectional communication with caregivers and parents Disseminate the therapeutic plan and clinical reasoning effectively in transparent manner
PC 2,6,7 ICS 1
ICS ¼ interpersonal and communication skills; MK ¼ medical knowledge; PC ¼ patient care; PMLI ¼ practice-based learning and improvement; PPD ¼ personal and professional development; SBP ¼ systems-based practice. a Modified from ten Cate and Scheele,17 CoPS,19 and ONTPD.20 b Please note that EPAs 1–5 cross the pediatric generalist to subspecialist role; 6–7 are common to all pediatric subspecialities; and 8–12 are specific to neonatology.
general criteria.23 Freely available videos suitable for medical education in ethics, professionalism, and communication can be found through New England Journal of Medicine (NEJM) videos in Cinical Medicine (although most focus on procedural skills), TED videos and YouTube.23,26–28 The Initiative for Pediatric Palliative Care is an excellent resource focusing on end-of-life care in pediatrics, including videos for purchase.29 Enacted difficult conversations with professional, improvisational actors has also been shown to be effective in teaching ethics, professionalism, and communication skills to medical trainees and faculty.30–32 One study reported that nearly all of the participating interprofessional learners (L) and teaching faculty (F) “found the actors realistic (98% L, 96% F), and valuable to learning (97% L, 100% F),” and that “most felt that role-play with another clinician would not have been as valuable as learning with actors (80% L, 97%F).”32 Similarly, simulation has been successfully used to highlight challenging ethical dilemmas and teach and assess communication and relational skills in a safe, realistic yet non-judgmental environment.33,34 The use of professional actors and simulation in ethics education can be admittedly costly and
resource-intensive, although should be considered as useful teaching tools if available. Interactive online ethics education for pediatric health professionals has also recently been shown to be practical, effective, and valuable.35 The 9-month curriculum consisted of blended learning methods, including an on-site orientation, weekly assigned reading and online discussion modules, critical analysis (e.g., mock ethics consultation and mock institutional ethics review board case), webinars, and final capstone project. The authors highlight several key factors contributing to the success of the program, including multidisciplinary faculty participants, clear criteria for completing the course, and the need for maintaining flexibility within the curriculum. Finally, bedside teaching can be an extremely effective method for teaching ethics and professionalism in the NICU. The art of bedside teaching has a long and powerful history in medicine, emphasized and advocated by monumental physician–educators such as Hippocrates, Sylvius, and Sir William Osler.36 As Truog et al.37 point out, ethical issues arise daily in everyday clinical decisions, relational judgments, and interactions with patients and families. This approach, termed
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Table 2 – Summary of 4 learning styles, modes, associated traits, and preferred learning methods.22,a Learning style
Preferred learning mode
Associated characteristics
Preferred learning method
Diverging
Concrete experience
Imaginative Emotional Interested in people Likes to gather information Generates ideas well Brainstorms well Listens with open mind
Small group exercise Online module Video Enacted role-play Prefers personalized feedback
Understands wide range of information; able to condense into concise, logical form
Assigned reading Lecture Online module Video Analytical model Prefers to have time to think things through
Reflective observation
Assimilating
Abstract conceptualization Reflective observation
Interested in ideas and abstract concepts Less interested in people Values theoretical logic over practical value Converging
Abstract conceptualization Active experimentation
Accommodating
Concrete experience Active experimentation
a
Problem-solver Decision-maker Excels at finding practical uses for ideas and theories Prefer technical tasks over social/ interpersonal issues
Small group exercise Simulation Bedside teaching Facilitated observation and feedback
Action-oriented Tendency to rely on people for information rather than own analysis Tendency to act on “gut feeling” rather than logical analysis Enjoys new challenges and carrying out plans
Group exercise Simulation Bedside teaching “Hand-on” experience in the field Facilitated observation and feedback
Adapted from Kolb et al.22 Please note that an individual learner is likely to be a combination of styles; preferred learning methods may vary.
“microethics,” or “the ethics of everyday clinical practice” can be effectively incorporated by faculty at the bedside in the NICU.37 A 6-step model of clinical bedside teaching, termed “microskills,”36 can be adapted to complement “microethics” and guide the teacher at the bedside in the NICU: (1) get a commitment from the trainee, to commit to a decision or ethical course of action, (2) probe for supporting evidence (moral reasoning, ethical principles, and frameworks) to support his/her impression, (3) teach general rules, focus on a few key ethical concepts, (4) reinforce what was done well, to encourage moral reasoning, “increase learner’s confidence and encourage conscious repetition in the future,”36 (5) correct mistakes, after first probing the learner to evaluate their own performance, (6) identify future learning steps, to support the growth of moral and ethical reasoning skills and behavior throughout the learner’s career.36,37 Self-reflection is crucial for any learner to recognize academic and personal strengths, as well as areas for improvement, and allow for continued growth and development over time. Narrative ethical inquiry, informal, and unstructured essays written in small groups during class or on the learner’s own time contemplating the ethics of everyday clinical
interactions, can aid in self-reflection, and allow learners to process difficult encounters or conversations in the NICU, both emotionally and academically. A meta-analysis of ethics education for 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.”38 An ethics and professionalism curriculum that integrates multiple learning methods and media, including both didactic and practical hands-on application, as well as self-reflection, may prove to be the most effective, to capture various learning styles and ensure mastery of both knowledge and skills in these domains. More studies are needed to determine optimal teaching methods in this area.
Teaching resources Currently available resources and curricula in ethics and professionalism are summarized in Table 5. The American Academy of Pediatrics (AAP) Bioethics Curriculum39 and the ABP Teaching and Assessing Professionalism: Guide for Program Directors40 are excellent resources, as is the textbook
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Table 3 – Assessment strategies and tools, and corresponding testing domains. Assessment strategy/tool
Assessment domain
Written or online test True/false Multiple-choice Essay
Knowledge
Direct clinical observation* Short practice (5–15min) Long practice (shift, rotation)
Knowledge Skills Behavior
Case-based discussion/inquirya After clinical encounter or procedure, “What if… ?
Knowledge
Simulation
Knowledge, skills, and behavior Skills and behavior
360-degree evaluation (staff, peers, and families) Self-assessment
Knowledge, skills, and behavior Knowledge, skills, and behavior
Individualized learning plan a
Modified from ten Cate and Scheele
17
and ten Cate.
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Clinical Ethics in Pediatrics—A Case-Based Approach edited by Diekema et al.41 Kesselheim et al.42 have published a curriculum for pediatric interns and residents on Fostering Humanism and Professionalism, available through MedEdPORTAL Publicationss, a free online publication service provided by the Association of American Medical Colleges. These resources focus largely on ethical issues in general pediatrics, and are more broadly aimed at pediatric residents rather than neonatology fellows. They are also primarily text-based, or involve small group discussions, thus lacking the “hands-on interactive educational learning that is essential in developing communication and relational skills.”18 Several curricula in ethics education have been described in the literature, but few of these offer content or detailed teaching or assessment methods. Salih et al.8 provide a useful topic outline for a 3-year ethics and professionalism Table 4 – Teaching methods in ethics and professionalism in neonatology. Teaching method Didactic lecture Assigned reading (journal articles and texts) Case-based group discussion Online module Video Enacted difficult conversations with professional actors Simulation Bedside ethics teaching/“Microethics” Narrative inquiry/self-reflection Facilitated observation and feedback Daily clinical practice Clinical ethics consultation Clinical ethics rotation
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curriculum for neonatal–perinatal fellows. A structured endof-life curriculum for neonatal–perinatal post-doctoral fellows demonstrates increasing fellow knowledge regarding “patient qualifications for comfort care and withdrawal of support” in the pediatric setting.43 Daboval et al.44 also describe a 2-year innovative, holistic curriculum in Canada, with 3 associated Neonatal Ethics Teaching Program—Scenario-Oriented Learning in Ethics modules specific to neonatology (critically ill newborn in the NICU, antenatal consultation at the limit of viability, and unexpected birth malformation) available through MedEdPortal Publicationss.45–47 The Initiative for Pediatric Palliative Care, previously mentioned, is an excellent resource focusing solely on pediatric end-of-life care with a freely available curriculum consisting of 5 modules, in addition to videos for purchase.29,48
Assessing ethics and professionalism Appropriate assessment is crucial to drive further learning. Just as evidence for the best pedagogical methods to teach ethics and professionalism are lacking in neonatology, evidence for optimal strategies for assessment in these areas are also lacking. As discussed above, many neonatal–perinatal training programs and their associated Clinical Competency Committees (CCC) have largely struggled with how best to assess competencies, milestones, and EPAs, particularly those related to ethics and professionalism.17,19,20 Yet, despite existing challenges, assessment in these domains is impossible without some type of measurement.49
Formative and summative assessment Formative assessment evaluates a learner in the middle of an instructional unit (e.g., halfway through a clinical rotation) to immediately identify strengths and areas for improvement via feedback. Summative assessment evaluates a learner at the end of an instructional unit, by comparing it to a benchmark or standard (e.g., the end of a clinical rotation or the end Table 5 – Currently available resources and curricula in ethics and professionalism. Ethics and professionalism resources AAP Bioethics Resident Curriculum39 http://www.aap.org/sections/bioethics/default.cfm ABP Teaching and Assessing Professionalism: A Guide for Program Directors40 http://www.appd.org/professionalism.pdf Textbook Clinical Ethics in Pediatrics—A Case-Based Approach41 MedEdPortals http://https://www.mededportal.org/about/ Neonatal Ethics Teaching Program—scenario-oriented learning in ethics45–47 Fostering humanism and professionalism42 Initiative for Pediatric Palliative Care Curriculum48 http://www.ippcweb.org./curriculum.htm
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of the first year of fellowship). The ACGME requires that a formative evaluation for each fellow, including assessment of the 6 core competencies in clinical care, take place at the end of each rotation, using “multiple evaluators” to “document progressive performance improvement appropriate to his/her educational level.”13,50 Neonatal–perinatal training programs must also provide a summative evaluation for each fellow upon completion of the program to confirm that the fellow is capable of performing unsupervised EPAs competently.13,50
Assessment strategies and tools Assessment strategies and currently available tools relevant to neonatology are summarized in Table 3, along with the correlating tested domain (knowledge, skills, and behavior). To accurately assess knowledge and application of ethical principles and frameworks, as well as moral reasoning, professionalism, and communication skills in practice, strategies, and tools should encompass all 3 domains longitudinally. In general, cognitive skills or knowledge may be evaluated with written or online exams; technical skills can be assessed via simulation or in practice; and behavior skills, more difficult to evaluate, can be assessed via simulation, enacted clinical scenarios, or in practice.50 The ABP guide on Teaching and Assessing Professionalism for Program Directors is a valuable resource, although focuses primarily on professionalism.40 A written or online test may be used as one tool to assess a student’s knowledge in ethics relevant to the practice of neonatology. A test may include True/False questions, multiple-choice questions, essay questions, or a combination of formats. Tests may be used as a formative or summative cognitive assessment, may help identify individual knowledge gaps and areas for improvement, and may also help to guide curricular development. Such tests, however, lack the capacity to assess the student’s application of knowledge, clinical skills or behaviors in practice. Currently, there is no standardized test to assess ethics knowledge in neonatal– perinatal fellows, although our group is in the process of validating one tool for this potential use. Direct clinical observation by supervising attendings can be particularly useful for assessing ethics and professionalism in practice. Such observation can be divided into 2 types described by ten Cate51 as short practice or long practice.17 “Short practice” involves direct observation of the trainee while performing a discrete task in clinical practice, usually lasting 5–15 minutes, such as obtaining informed permission from parents for a procedure, or discussion of withdrawal of life-sustaining interventions with parents. “Long practice” involves direct observation of the fellow in clinical practice over a longer time frame, such as a 24-hour shift or a monthlong rotation. Both types of observations are important in order to assess knowledge and skills, as well as behavior, which occur over time.51 Another assessment strategy for faculty who directly supervise fellows in practice utilizes case-based discussion and inquiry.51 This method prompts the supervising attending to probe the fellow after an otherwise ordinary event in the NICU, such as performing a procedure or having a conversation with a parent, with a theoretical ethical
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dilemma. Questions such as, “What would you have done if you had made an error… ?” or “What if the parent had said… ?” or “What would you do if… ?” This simple yet, effective strategy can help highlight the ethics of everyday clinical practice and assess moral reasoning skills, even without direct observation. As discussed above, simulation can be an effective tool to teach as well as assess ethical and moral reasoning skills, professionalism, and interpersonal and communication skills.33 Simulation provides a safe, non-judgmental environment for fellows to actively participate in high stakes, challenging ethical dilemmas, and difficult conversations.33 Loo et al.52 developed an assessment tool or framework, called the Professionalism Matrix, available through MedEdPORTALs, to analyze professional and unprofessional behaviors in clinical practice. This tool may also be used to teach trainees, and may be used during simulation as well as clinical practice. Peterson et al.53 confirmed the reliability of a modified Gap-Kalamazoo Communication Skills Assessment Form when assessing the communication skills of multidisciplinary learners in simulation, with high internal consistency and high inter-rater reliability. This assessment tool may be useful in evaluating neonatal–perinatal fellows’ communication skills both in simulated environments as well as during direct clinical observation. Another group has published a tool to teach and assess communication skills in the delivery room (Delivery Room Communication Checklist), available through MedEdPORTALs.54 Required rotations for neonatal–perinatal fellows of varying lengths in multiple hospital settings poses even further challenges when attempting to assess ethics and professionalism, interpersonal skills, and communication abilities. The 360-degree evaluation is a tool that can evaluate a trainee’s clinical competence in these areas using data and feedback from multiple key sources within a trainee’s learning environment.49,55 Evaluations can be solicited from the entire interprofessional medical team including “neonatologists, neonatology fellows, pediatric residents, medical students, nurses, neonatal practitioners, respiratory therapists, social workers, and other clinicians who interact with the trainee (e.g., nutritionists and pharmacists),” as well as families.55 The 360-degree assessment tool can help uncover discrepancies between family and staff perspectives regarding professionalism and communication, and “motivate trainees to modify their performance.”55 Self-assessment is crucial to the process of personal growth and improvement. Most trainees are already keenly aware of academic strengths and struggles and able to identify areas for improvement. A 360-degree evaluation should also be completed by the trainee himself/herself. Correlation of an individual learner’s 360-degree assessments and self-assessments, however, may reveal “gaps” or “blind spots, which are clinical behaviors that the trainee is unaware that he or she does or does not do and can consist of hidden strengths or unknown weaknesses.”55 An individualized learning plan (ILP) should be used by all fellows and faculty to aid in the process of self-assessment and self-directed learning, to “identify strengths and weaknesses, formulate learning goals, and track progress” as part of a lifelong learning process.56
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Role of the clinical competency committee The Clinical Competency Committee (CCC) of each neonatal– perinatal training program has been charged with the difficult yet, important task of assessing individual learner’s competencies, milestones, and readiness for independently performing EPAs. This includes assessment of ethical and professional knowledge and skills, as well as relational and communication skills. Several studies have shown that group assessment is superior to individual assessment at uncovering deficiencies in professionalism among students.57,58 It is thus important that the CCC meet as a group to discuss individual fellow performance regularly, as required by the ACGME.
Conclusions and future research There is growing interest in ethics and professionalism education in neonatology, however, evidence-based studies to determine the most effective teaching methods and assessment strategies are still lacking. A “flipped classroom” approach to teaching medical ethics and professionalism in neonatology may be effective, in which students learn course material online via multimedia modules on their own time, then come to class sessions prepared to engage in a variety of educational activities, including in-depth group discussion, enacted role-play, and simulation. This model would engage students with various preferred learning styles, and enable mastery of both knowledge and practical skills in ethics and professionalism during training when time is scarce. Our group is in the process of piloting such an innovative ethics and professionalism curriculum for neonatal–perinatal fellows, as well as developing and validating 2 assessment tools. Outcomes-based research is still needed to determine optimal teaching methods as well as assessment strategies in ethics and professionalism in neonatology to ensure trainees not only achieve competency in these domains, but also to ensure the formation of professional, virtuous clinicians with excellent moral and ethical reasoning skills for the ultimate benefit of the patients and their families.
r e f e r e n c e s
1. Association of American Medical Colleges Medical School Objectives Project. Learning Objectives for Medical Student Education: Guidelines for Medical Schools. . Washington, DC: Association of American Medical College; 1998. 2. Eckles R, Meslin EM, Gaffney M, Helft PR. Medical ethics education: where are we? where should we be going? a review. Acad Med. 2005;80(12):1143–1152. 3. Mattick K, Bligh J. Teaching and assessing medical ethics: where are we now? J Med Ethics. 2006;32(3):181–185. 4. Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85(2):318–323. 5. Doukas DJ, Kirch DG, Brigham TP, et al. Transforming educational accountability in medical ethics and humanities education toward professionalism. Acad Med. 2015;90(6):738–743.
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6. Carrese JA, Malek J, Watson K, et al. The essential role of medical ethics education in achieving professionalism: the Romanell Report. Acad Med. 2015;90(6):744–752. 7. Bolin J. Strategies for incorporating professional ethics education in graduate medical programs. Am J Bioeth. 2006;6(4):35–36. 8. Salih Z, Boyle D. Ethics education in neonatal–perinatal medicine in the United States. Semin Perinatol. 2009;33(6):397–404. 9. Davis D, Doucet H. A curriculum for teaching clinical ethics in neonatal–perinatal medicine. Ann R Coll Phys Surg Can. 1996; 29(1):45–48. 10. Stirrat G. Education in ethics. Clin Perinatol. 2003;30(1):1–15. 11. 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. 12. 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. 13. Accreditation Council for Graduate Medical Education. General competencies. http://acgme.org/acgmeweb/Portals/0/PDFs/com monguide/IVA5e_EducationalProgram_ACGMECompetencie s_Professionalism_Explanation.pdf; Accessed 21.10.15. 14. American Board of Pediatrics. The Pediatrics Milestones Project. https://www.abp.org/abpwebsite/publicat/milestones.pdf; Accessed 22.10.15. 15. Schumacher DJ, Spector ND, Calaman S, et al. Putting the pediatric milestones into practice: a consensus roadmap and resource analysis. Pediatrics. 2014;133(5):898–906. 16. Stevenson DK, McGuiness GA, Bancroft JD, et al. The initiative on subspecialty clinical training and certification (SCTC): background and recommendations. Pediatrics. 2014;133(S2): S53–S57. 17. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice. Acad Med. 2007;86(2):161–165. 18. Cummings CL, Geis GM, Kesselheim JC, Sayeed S. Ethics and professionalism education during Neonatal–Perinatal Fellowship training in the United States. J Perinatol. 2015;35(10): 875–879. 19. Parker T, Guttentag S and Rice W Council of Pediatric Subspecialties (CoPS), Subspecialty Specific Entrustable Professional Activities in Neonatology. www.pedsubs.org/issues/ EPAs_Neonatology.cfm; Accessed 21.10.15. 20. Goals and objectives in Neonatal–perinatal Medicine Fellowship training. https://www2.aap.org/sections/perinatal/ ONTPDfiles/ONTPDgoals.pdf; Accessed 21.10.15. 21. Kelly CD, Kolb DA. The theory of experiential learning and ESL. Internet TESL J. 1997;3(9):1–6. 22. Kolb DA, Boyatzis RE, Mainemelis C. Experiential learning theory: previous research and new directions. In: Sternberg RJ, Zhang L, et al., eds. Perspectives On Thinking, Learning And Cognitive Styles. New York: Routledge; 2001. 227–247. 23. Hurtubise L, Martin B, Gilliland A, Mahan J. To play or not to play: leveraging video in medical education. J Grad Med Educ. 2013;5(1):13–18. 24. Dong C, Goh PS. Twelve tips for the effective use of videos in medical education. Med Teach. 2015;37(2):140–145. 25. Jang HW, Kim KJ. Use of online clinical videos for clinical skills training for medical students: benefits and challenges. BMC Med Educ. 2014;14:56. 26. New England Journal of Medicine. Videos in clinical medicine. N Engl J Med website. Available at: http://www.nejm.org/ multimedia/medical-videos; Accessed 26.10.15. 27. Technology, Entertainment, Design Conferences LLC. Ideas worth spreading. TED website. Available at: http://www.ted. com/talks/browse; Accessed 26.10.15. 28. YouTube. YouTube website. Available at: http://www.you tube.com; Accessed 26.10.15.
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29. Institute for Pediatric Palliative Care Videos. Available at http://www.ippcweb.org./video.htm; Accessed 27.10.15. 30. Lamiani G, Meyer EC, Browning DM, Brodsky D. Analysis of enacted difficult conversations in neonatal intensive care. J Perinatol. 2009;29(4):310–316. 31. 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. 32. Bell SK, Pascucci RC, Fancy KM, Coleman K, Zurakowski D, Meyer EC. The educational value of improvisational actors to teach communication and relational skills: perspectives of interprofessional learners, faculty, and actors. Patient Educ Couns. 2014;96(3):381–388. 33. Gisondi MA, Smith-Coggins R, Harter PM, Soltysik RC, Yarnold PR. Assessment of resident professionalism using highfidelity simulation of ethical dilemmas. Acad Emerg Med. 2004;11(9):931–937. 34. Calhoun AW, Rider EA, Meyer EC, Lamiani G, Truog RD. Assessment of communication skills and self-appraisal in the simulated environment: feasibility of multi-rater feedback with gap analysis. Simul Healthc. 2009;4(1):22–29. 35. Plantz DM, Garrett JR, Carter B, Knackstedt AD, Watkins VS, Lantos J. Engaging pediatric health professionals in interactive online ethics education. Hastings Cent Rep. 2014;44(5): 15–20. 36. Doherty EG, Brodsky D. Bedside teaching: rediscovering a lost art. NeoReviews. 2012;23(5):e271–e280. 37. Truog RD, Brown SD, Browning D, et al. Microethics: the everyday ethics of clinical practice. Hastings Cent Rep. 2015;45(1):11–17. 38. Antes AL, Murphy ST, Waples EP, et al. A meta-analysis of ethics instruction effectiveness in the sciences. Ethics Behav. 2009;19(5):379–402. 39. Adam MB, Diekema DS, Mercurio MR, eds. American Academy of Pediatrics Bioethics Resident Curriculum: Case-Based Teaching Guides. Available at: http://www.aap.org/sections/ bioethics/default.cfm; Accessed 27.10.15. 40. American Board of Pediatrics, Program Directors Committee; Association of Pediatric Program Directors. Teaching and Assessing Professionalism: A Program Director’s Guide. Chapel Hill, NC: American Board of Pediatrics Foundation; 2008. Available at: www.appd.org/professionalism.pdf; Accessed 27.10.15. 41. Diekema DS, Mercurio MR, Adam MB, et al., eds. Clinical Ethics in Pediatrics–A Case-Based Approach. Cambridge, England: Cambridge University Press; 2011. 42. Kesselheim J, Garvey K, Sectish T, Vinci R Fostering Humanism and Professionalism in Pediatric Residency Training. MedEdPORTAL Publications; 2010. Available at: https://www. mededportal.org/publication/7906; Accessed 27.10.15. 43. Harris LL, Placencia FX, Arnold JL, Minard CG, Harris TB, Haidet PM. A structured end-of-life curriculum for neonatal– perinatal postdoctoral fellows. Am J Hosp Palliat Med. 2015; 32(3):253–261. 44. 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.
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45. Moore G, Ferretti E, Rohde K, Muirhead P, Daboval T Neonatal Ethics Teaching Program—Scenario-Oriented Learning in Ethics: Critically Ill Newborn in the Neonatal Intensive Care Unit. MedEdPORTAL Publications; 2015. Available at: https:// www.mededportal.org/publication/10083; Accessed 27.10.15. 46. Daboval T, Ferretti E, Rohde K, Muirhead P, Moore G Neonatal Ethics Teaching Program—Scenario-Oriented Learning in Ethics: Antenatal Consultation at the Limit of Viability. MedEdPORTAL Publications; 2015. Available at: https://www. mededportal.org/publication/10043; Accessed 27.10.15. 47. Ferretti E, Moore G, Rohde , Muirhead P, Daboval T Neonatal Ethics Teaching Program - Scenario-Oriented Learning in Ethics: Unexpected Birth Malformation. MedEdPORTAL Publications; 2015. Available at: https://www.mededportal.org/ publication/10044; Accessed 27.10.15. 48. Initiative for Pediatric Palliative Care Curriculum. Available at http://www.ippcweb.org./curriculum.htm; Accessed 27.10.15. 49. Lynch DC, Surdyk PM, Eiser AR. Assessing professionalism: a review of the literature. Med Teach. 2004;26(4):366–373. 50. Halamek LP. Educational perspectives: rigorous human performance assessment in neonatal–perinatal medicine. NeoReviews. 2013;14(9):e379–e386. 51. ten Cate O Entrustable professional activities as a framework for assessment. Presentation at the 2015 ACGME Annual Educational Conference, SES094, on February 28, 2015. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/ 2015%20AEC/Presentations/SES094.pdf; Accessed 28.10.15. 52. Loo L, Geslani V, Baz S, Tudtud-Hans L The Professionalism Matrix: A Framework to Analyze Professional & Unprofessional Behaviors. MedEdPORTAL Publications; 2014. Available at: https:// www.mededportal.org/publication/9961; Accessed 28.10.15. 53. Peterson EB, Calhoun AW, Rider EA. The reliability of a modified Kalamazoo consensus statement checklist for assessing the communication skills of multidisciplinary learners in the simulated environment. Patient Edu Couns. 2014;96(3):411–418. 54. Dadiz R, Weinschreider J, Guillet R, Pressman E The Delivery Room Communication Checklist. MedEdPORTAL Publications; 2014. Available at: https://www.mededportal.org/publication/ 9797; Accessed 28.10.15. 55. Doherty EG, Brodsky DB. Educational perspectives: the 360degree assessment: a new paradigm in trainee evaluation. NeoReviews. 2011;12(4):e191–e197. 56. Chapman R. Educational perspectives: the individualized learning plan: supporting the self-directed learning process. NeoReviews. 2012;13(4):e207–e212. 57. Hemmer P, Hawkins R, Jackson J, Pangaro L. Assessing how well three evaluation methods detect deficiencies in medical students’ professionalism in two settings of an internal medicine clerkship. Acad Med. 2000;75(2):167–173. 58. Schwind CJ, Williams RG, Boehler ML, Dunnington GL. Do individual attendings’ post-rotation performance ratings detect residents’ clinical performance deficiencies. Acad Med. 2004;79(5):453–457.
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Available online at www.sciencedirect.com
Seminars in Perinatology www.seminperinat.com
Teaching and assessing ethics in the newborn ICU Christy L. Cummings, MD Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Hunnewell 437, Boston, MA
article info
abstra ct
Keywords:
Ethics and professionalism education has become increasingly recognized as important
Ethics
and incorporated into graduate medical education. However, such education has remained
Professionalism
largely unstructured and understudied in neonatology. Neonatal–perinatal fellowship
Communication
training programs have generally grappled with how best to teach and assess ethics and
Graduate medical education
professionalism knowledge, skills, and behavior in clinical practice, particularly in light of
Training
accreditation requirements, milestones, and competencies. This article reviews currently
Neonatology
available teaching methods, pedagogy, and resources in medical ethics, professionalism,
Assessment
and communication, as well as assessment strategies and tools, to help medical educators
Milestones
and practicing clinicians ensure trainees achieve and maintain competency. The need for
Competency
consensus and future research in these domains is also highlighted.
Entrustable professional activity
Introduction Ethics and professionalism education has become increasingly recognized as important for the development of a physician capable of moral introspection and effective navigation of ethical dilemmas and challenging situations in clinical practice. Teaching focused on ethics and professionalism has been incorporated into both medical school and graduate medical education.1–7 Such education, however, has remained largely unstructured and understudied in neonatology.8–12 Neonatal–perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies set forth by the Accreditation Council for Graduate Medical Education (ACGME)13 and the American Board of Pediatrics (ABP) via the Milestones Project.14–17 A recent national study by our group showed that participating neonatal–perinatal fellows and recent graduates were dissatisfied with their training in ethics education, and significantly less likely to rate the ethics education
& 2016 Elsevier Inc. All rights reserved.
provided during fellowship as “excellent/very good” than program directors (37% vs. 63%, p ¼ 0.004).18 Although over 97% of respondents agreed that ethics training is “important/very important,” and 96% of program directors reported the inclusion of ethics education for fellows, only 70% of fellows and recent graduates reported such teaching (p o 0.001), signaling a continued need for curricular improvement in this area.18 This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency in neonatology. Finally, the need for consensus and future research in these domains is also highlighted.
Ethics and professionalism goals and objectives Studies have shown that most students arrive at medical school with well-established ethical and moral perspectives.2
The author is grateful for support from the Division of Newborn Medicine at Boston Children’s Hospital, Boston, MA. This work is supported in part by a grant from the Arnold P. Gold Foundation (grant Id no. FI-15-005), United States. E-mail address: [email protected] http://dx.doi.org/10.1053/j.semperi.2015.12.016 0146-0005/& 2016 Elsevier Inc. All rights reserved.
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By the time trainees arrive at neonatology fellowship, many will have taken some form of ethics class or course. The goal of medical ethics education in neonatology is, thus, to further augment and refine existing ethics knowledge, and skills, while also introducing novel concepts and frameworks specific to the field of neonatology, in order to develop virtuous neonatologists with the necessary skills to effectively and compassionately recognize, analyze and resolve ethical dilemmas in the neonatal intensive care unit (NICU).2 The goal is to teach trainees in neonatal–perinatal medicine to move beyond a simplistic mastery of ethics principles, to develop adaptive expertise such that they are able to creatively and flexibly extend existing knowledge and skills to novel or unexpected ethical situations in practice. Many of these skills and behaviors are deemed to be essential by accreditation organizations, such as the ACGME and the ABP, for graduation from neonatal–perinatal fellowship training programs.13–17,19,20
Competencies, milestones, and entrustable professional activities (EPAs) Every pediatric subspecialty trainee, including neonatal–perinatal medicine fellows, must demonstrate (1) competency along 6 broad domains (patient care ¼ PC, medical knowledge ¼ MK, practice-based learning and improvement ¼ PBLI, interpersonal and communication skills ¼ IPCS, personal and professional development ¼ PPD, and systems-based practice ¼ SBP), (2) adequate progression along meaningful milestones within each domain relevant to clinical practice, and (3) the ability to perform designated entrustable professional activities (EPAs) effectively and without supervision.14–17 Competencies may be viewed as knowledge or skill, while EPAs are essential tasks in clinical practice that can be observed in a discreet time frame.17 To successfully perform an EPA, a learner must not only have mastered single competencies, but must have the ability to autonomously integrate them together.17 Many neonatal–perinatal training programs and their associated Clinical Competency Committees (CCC) have largely struggled with how best to link competencies, milestones, and EPAs, particularly those related to ethics and professionalism, which overlap and may be more difficult to define and assess.17,19,20 Table 1 modified from the work of ten Cate and Scheele,17 Council of Pediatric Subspecialties (CoPS),19 and Organization of Neonatal Training Program Directors (ONTPD),20 summarizes EPAs, selected milestones and competencies relevant to ethics and professionalism in neonatology.13–16
Teaching ethics and professionalism Pedagogy and teaching methods Adult learning theory states that learners learn best when education is self-directed, goal oriented and practical, built on life experiences (experiential learning), and existing frameworks.21,22 Knowledge results from a continuous cycle of grasping and transforming these experiences, through
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concrete experience, abstract conceptualization, reflective observation, and active experimentation.22 Further, adult learners learn best when given their preferred learning method, which complements their learning style. A summary of 4 learning styles, described by Kolb, is outlined in Table 2, along with associated characteristics and preferred learning methods.21,22 Note, however, that an individual learner is likely to be a combination of styles; preferred learning methods may vary. Thus, a variety of teaching methods, woven into a hybrid curriculum, is more likely to effectively teach knowledge and skills to a group of adult learners. A variety of teaching methods may be used to teach ethics and professionalism in neonatology (Table 4). Neonatal– perinatal fellows and recent graduates reported in our study several learning methods to be more effective than others, specifically discussions with supervising attendings, hospital ethicists and peers, involvement in family meetings and ethics consultations, teaching conferences, assigned reading in medical journals, and simulation.18 While perceived effectiveness may not always correlate with actual learning, these results suggested that those methods in ethics education were well received. We also found that in addition to formal training in ethics education, increased trainee leadership in ethics discussions and consults with supervising attendings and clinical ethicists was desired by fellows and may be extremely valuable.18 Such facilitated observation and feedback in clinical practice can be particularly effective in teaching ethics and professionalism. Physician–educators and clinical faculty should serve as role models to continue to inspire subsequent generations of neonatologists to be virtuous, compassionate clinicians adept at navigating modern ethical challenges in the NICU. Several studies have found that small group discussions of ethics to be significantly more effective than lecture courses in developing moral reasoning skills.2 Numerous studies have also shown that thoughtful and strategic use of video in medical education can be a powerful and effective teaching and learning tool.23–25 Videos can quickly relay key concepts, particularly those that are more abstract such as ethics and professionalism, while reaching learners with various preferred learning and communication styles.23 When skillfully integrated into a lecture class or group discussion, the use of video can: (1) “Present more information in a given amount of space and time. (2) Simplify complex concepts. (3) Clarify pieces of abstract language-based concepts (4) Demonstrate concepts/subjects that are in motion and/or relate to one another. (5) Be more efficient and effective at getting audience attention.”23
When incorporating video clips into sessions, one must be cognizant of copyright considerations. The fair use statute allows for appropriate use of copyrighted material (including video) without permission, provided that the use is socially useful, such as scholarship or research, and meets other
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Table 1 – Entrustable Professional Activities (EPAs) and selected milestones mapped to competencies relevant to ethics and professionalism in neonatology.a Entrustable professional activity (EPA)b
Selected milestones (relevant to ethics and professionalism in neonatology)
Competency
(1) Apply public health principles and improvement methodology to improve the health of populations, communities, and systems
Collaborate with others to improve systems of neonatal care Recognize one’s professional responsibility to populations, communities, and society Utilize risk-benefit and cost-benefit analysis Engage actively in the stewardship of resources in the NICU
PBLI 4,7 SBP 3–7 PPD
(2) Provide for and obtain consultation from other health care providers caring for children
Communicate key information when engaging another consultant Help families in the NICU, deal with uncertainty in the diagnosis or prognosis that requires engagement of the consultant
PC 6 PBLI 1 ICS 3–5 SBP 2 PPD 8
(3) Contribute to the fiscally sound and ethical management of a practice (through billing, scheduling, coding, and record keeping practices)
Billing (accurately, honestly, and compliant) Document accurately and honestly to serve the needs of the patient and comply with regulatory requirements Provide care with attention to cost-benefit analyses
SBP 1– 6PPD
(4) Facilitate handovers to another health care provider
Engage in bidirectional communication of plans and expectations with families and caregivers Provide feedback to individual initiating handover of any errors that occurred, including inaccurate information transmission
ICS 3,6 PBLI 5,7
(5) Lead and work within interprofessional health care teams
Elicit and value perspective and contributions of others on team Balance autonomy and appropriate supervision of team members Recognize and manage social cues, emotional responses, and personal/professional needs of team members Role modeling
PBLI 8,9 ICS 2,4 SBP 5 PPD 4,6
(6) Engage in scholarly activities through the discovery, application, and dissemination of new knowledge
Critical analysis of one’s own work as well as work of others Conduct high-quality research Demonstrate ethical principles and practices in conducting scholarly activities and research
PBLI 2–9 ICS PPD
(7) Lead within the subspecialty profession
Advocate for issues in neonatal–perinatal medicine, recognizing vulnerabilities unique to this population (eg., infants, premature infants at the limits of viability, infants with congenital anomalies or neurologic injury/ deficits)
ICS 1,4 SBP 4,7 PPD 4,6
(8) Management of neonatal care systems
Prioritize deployment of resources to those with highest acuity or needs Develop a utilization plan that incorporates prioritized needs of individual patients, the composition and capabilities of personnel with environment (NICU, transport, OR, DR, etc), and the needs of the parents and family Recognize limits and ask for help Communicate utilization and deployment plans to personnel in succinct and timely manner
PC 2 SBP 2, 5PPD 6
(9) Manage patients with complex, multisystem diseases in the NICU
Coordinate inter-disciplinary care of the complex neonate, including reconciling disparate opinions from other health care professionals, parents, and family Manage uncertainties at the personal, team, and family level (eg., Is there sufficient evidence to offer and/or recommend this treatment option to the family? Are we doing the right thing?) Lead a complicated family discussion (DNR or WLST) Convey bad news (including undesired results and poor prognosis) and disclosing medical error or lifethreatening complications
PC 9 MK 2 PBLI 1,6 SBP 2 ICS 4 PPD 8 PROF 5,6,8
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Table 1 (continued) ) Entrustable professional activity (EPA)b
Selected milestones (relevant to ethics and professionalism in neonatology)
Competency
Identify key ethical principles used in decision-making and apply them to common ethical scenarios in neonatology Provide compassionate medical care and empathetic support to critically ill infants near the end of life, and their families Maintain high standards of ethical behavior, including maintaining appropriate professional boundaries Establish trust that makes colleagues feel secure when one is responsible for the care of patients (10) Provide care to patients in the NICU with surgical problems in collaboration with pediatric and subspecialty surgeons
Recognize conditions where surgery is indicated, including knowledge of one’s own limitations of one’s ability to manage problems medically Communicate directly with pediatric/subspecialty surgeon to facilitate timely and coordinated care of neonates with surgical needs Provide continuity of care that insures parents and families understand diagnosis, prognosis, and uncertainties
ICS 3,5 SBP 2 PPD 1,2
(11) Provide resuscitation and stabilization of neonates and infants, which aligns care with severity of illness
Anticipate and recognize the sick infant requiring resuscitation, including effective antenatal counseling and counseling after delivery Effectively lead an interprofessional team before, during, and after a resuscitation, including the ability to reflect on one’s own behaviors and provide effective feedback to team
PC 13 ICS 2 PPD 6,7 SBP 5
(12) Manage patients with acute, common single-system diseases in an inpatient setting
Place the patient at the center of all management decisions to provide patient- and family-centered care by engaging in bidirectional communication with caregivers and parents Disseminate the therapeutic plan and clinical reasoning effectively in transparent manner
PC 2,6,7 ICS 1
ICS ¼ interpersonal and communication skills; MK ¼ medical knowledge; PC ¼ patient care; PMLI ¼ practice-based learning and improvement; PPD ¼ personal and professional development; SBP ¼ systems-based practice. a Modified from ten Cate and Scheele,17 CoPS,19 and ONTPD.20 b Please note that EPAs 1–5 cross the pediatric generalist to subspecialist role; 6–7 are common to all pediatric subspecialities; and 8–12 are specific to neonatology.
general criteria.23 Freely available videos suitable for medical education in ethics, professionalism, and communication can be found through New England Journal of Medicine (NEJM) videos in Cinical Medicine (although most focus on procedural skills), TED videos and YouTube.23,26–28 The Initiative for Pediatric Palliative Care is an excellent resource focusing on end-of-life care in pediatrics, including videos for purchase.29 Enacted difficult conversations with professional, improvisational actors has also been shown to be effective in teaching ethics, professionalism, and communication skills to medical trainees and faculty.30–32 One study reported that nearly all of the participating interprofessional learners (L) and teaching faculty (F) “found the actors realistic (98% L, 96% F), and valuable to learning (97% L, 100% F),” and that “most felt that role-play with another clinician would not have been as valuable as learning with actors (80% L, 97%F).”32 Similarly, simulation has been successfully used to highlight challenging ethical dilemmas and teach and assess communication and relational skills in a safe, realistic yet non-judgmental environment.33,34 The use of professional actors and simulation in ethics education can be admittedly costly and
resource-intensive, although should be considered as useful teaching tools if available. Interactive online ethics education for pediatric health professionals has also recently been shown to be practical, effective, and valuable.35 The 9-month curriculum consisted of blended learning methods, including an on-site orientation, weekly assigned reading and online discussion modules, critical analysis (e.g., mock ethics consultation and mock institutional ethics review board case), webinars, and final capstone project. The authors highlight several key factors contributing to the success of the program, including multidisciplinary faculty participants, clear criteria for completing the course, and the need for maintaining flexibility within the curriculum. Finally, bedside teaching can be an extremely effective method for teaching ethics and professionalism in the NICU. The art of bedside teaching has a long and powerful history in medicine, emphasized and advocated by monumental physician–educators such as Hippocrates, Sylvius, and Sir William Osler.36 As Truog et al.37 point out, ethical issues arise daily in everyday clinical decisions, relational judgments, and interactions with patients and families. This approach, termed
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Table 2 – Summary of 4 learning styles, modes, associated traits, and preferred learning methods.22,a Learning style
Preferred learning mode
Associated characteristics
Preferred learning method
Diverging
Concrete experience
Imaginative Emotional Interested in people Likes to gather information Generates ideas well Brainstorms well Listens with open mind
Small group exercise Online module Video Enacted role-play Prefers personalized feedback
Understands wide range of information; able to condense into concise, logical form
Assigned reading Lecture Online module Video Analytical model Prefers to have time to think things through
Reflective observation
Assimilating
Abstract conceptualization Reflective observation
Interested in ideas and abstract concepts Less interested in people Values theoretical logic over practical value Converging
Abstract conceptualization Active experimentation
Accommodating
Concrete experience Active experimentation
a
Problem-solver Decision-maker Excels at finding practical uses for ideas and theories Prefer technical tasks over social/ interpersonal issues
Small group exercise Simulation Bedside teaching Facilitated observation and feedback
Action-oriented Tendency to rely on people for information rather than own analysis Tendency to act on “gut feeling” rather than logical analysis Enjoys new challenges and carrying out plans
Group exercise Simulation Bedside teaching “Hand-on” experience in the field Facilitated observation and feedback
Adapted from Kolb et al.22 Please note that an individual learner is likely to be a combination of styles; preferred learning methods may vary.
“microethics,” or “the ethics of everyday clinical practice” can be effectively incorporated by faculty at the bedside in the NICU.37 A 6-step model of clinical bedside teaching, termed “microskills,”36 can be adapted to complement “microethics” and guide the teacher at the bedside in the NICU: (1) get a commitment from the trainee, to commit to a decision or ethical course of action, (2) probe for supporting evidence (moral reasoning, ethical principles, and frameworks) to support his/her impression, (3) teach general rules, focus on a few key ethical concepts, (4) reinforce what was done well, to encourage moral reasoning, “increase learner’s confidence and encourage conscious repetition in the future,”36 (5) correct mistakes, after first probing the learner to evaluate their own performance, (6) identify future learning steps, to support the growth of moral and ethical reasoning skills and behavior throughout the learner’s career.36,37 Self-reflection is crucial for any learner to recognize academic and personal strengths, as well as areas for improvement, and allow for continued growth and development over time. Narrative ethical inquiry, informal, and unstructured essays written in small groups during class or on the learner’s own time contemplating the ethics of everyday clinical
interactions, can aid in self-reflection, and allow learners to process difficult encounters or conversations in the NICU, both emotionally and academically. A meta-analysis of ethics education for 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.”38 An ethics and professionalism curriculum that integrates multiple learning methods and media, including both didactic and practical hands-on application, as well as self-reflection, may prove to be the most effective, to capture various learning styles and ensure mastery of both knowledge and skills in these domains. More studies are needed to determine optimal teaching methods in this area.
Teaching resources Currently available resources and curricula in ethics and professionalism are summarized in Table 5. The American Academy of Pediatrics (AAP) Bioethics Curriculum39 and the ABP Teaching and Assessing Professionalism: Guide for Program Directors40 are excellent resources, as is the textbook
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Table 3 – Assessment strategies and tools, and corresponding testing domains. Assessment strategy/tool
Assessment domain
Written or online test True/false Multiple-choice Essay
Knowledge
Direct clinical observation* Short practice (5–15min) Long practice (shift, rotation)
Knowledge Skills Behavior
Case-based discussion/inquirya After clinical encounter or procedure, “What if… ?
Knowledge
Simulation
Knowledge, skills, and behavior Skills and behavior
360-degree evaluation (staff, peers, and families) Self-assessment
Knowledge, skills, and behavior Knowledge, skills, and behavior
Individualized learning plan a
Modified from ten Cate and Scheele
17
and ten Cate.
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Clinical Ethics in Pediatrics—A Case-Based Approach edited by Diekema et al.41 Kesselheim et al.42 have published a curriculum for pediatric interns and residents on Fostering Humanism and Professionalism, available through MedEdPORTAL Publicationss, a free online publication service provided by the Association of American Medical Colleges. These resources focus largely on ethical issues in general pediatrics, and are more broadly aimed at pediatric residents rather than neonatology fellows. They are also primarily text-based, or involve small group discussions, thus lacking the “hands-on interactive educational learning that is essential in developing communication and relational skills.”18 Several curricula in ethics education have been described in the literature, but few of these offer content or detailed teaching or assessment methods. Salih et al.8 provide a useful topic outline for a 3-year ethics and professionalism Table 4 – Teaching methods in ethics and professionalism in neonatology. Teaching method Didactic lecture Assigned reading (journal articles and texts) Case-based group discussion Online module Video Enacted difficult conversations with professional actors Simulation Bedside ethics teaching/“Microethics” Narrative inquiry/self-reflection Facilitated observation and feedback Daily clinical practice Clinical ethics consultation Clinical ethics rotation
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curriculum for neonatal–perinatal fellows. A structured endof-life curriculum for neonatal–perinatal post-doctoral fellows demonstrates increasing fellow knowledge regarding “patient qualifications for comfort care and withdrawal of support” in the pediatric setting.43 Daboval et al.44 also describe a 2-year innovative, holistic curriculum in Canada, with 3 associated Neonatal Ethics Teaching Program—Scenario-Oriented Learning in Ethics modules specific to neonatology (critically ill newborn in the NICU, antenatal consultation at the limit of viability, and unexpected birth malformation) available through MedEdPortal Publicationss.45–47 The Initiative for Pediatric Palliative Care, previously mentioned, is an excellent resource focusing solely on pediatric end-of-life care with a freely available curriculum consisting of 5 modules, in addition to videos for purchase.29,48
Assessing ethics and professionalism Appropriate assessment is crucial to drive further learning. Just as evidence for the best pedagogical methods to teach ethics and professionalism are lacking in neonatology, evidence for optimal strategies for assessment in these areas are also lacking. As discussed above, many neonatal–perinatal training programs and their associated Clinical Competency Committees (CCC) have largely struggled with how best to assess competencies, milestones, and EPAs, particularly those related to ethics and professionalism.17,19,20 Yet, despite existing challenges, assessment in these domains is impossible without some type of measurement.49
Formative and summative assessment Formative assessment evaluates a learner in the middle of an instructional unit (e.g., halfway through a clinical rotation) to immediately identify strengths and areas for improvement via feedback. Summative assessment evaluates a learner at the end of an instructional unit, by comparing it to a benchmark or standard (e.g., the end of a clinical rotation or the end Table 5 – Currently available resources and curricula in ethics and professionalism. Ethics and professionalism resources AAP Bioethics Resident Curriculum39 http://www.aap.org/sections/bioethics/default.cfm ABP Teaching and Assessing Professionalism: A Guide for Program Directors40 http://www.appd.org/professionalism.pdf Textbook Clinical Ethics in Pediatrics—A Case-Based Approach41 MedEdPortals http://https://www.mededportal.org/about/ Neonatal Ethics Teaching Program—scenario-oriented learning in ethics45–47 Fostering humanism and professionalism42 Initiative for Pediatric Palliative Care Curriculum48 http://www.ippcweb.org./curriculum.htm
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of the first year of fellowship). The ACGME requires that a formative evaluation for each fellow, including assessment of the 6 core competencies in clinical care, take place at the end of each rotation, using “multiple evaluators” to “document progressive performance improvement appropriate to his/her educational level.”13,50 Neonatal–perinatal training programs must also provide a summative evaluation for each fellow upon completion of the program to confirm that the fellow is capable of performing unsupervised EPAs competently.13,50
Assessment strategies and tools Assessment strategies and currently available tools relevant to neonatology are summarized in Table 3, along with the correlating tested domain (knowledge, skills, and behavior). To accurately assess knowledge and application of ethical principles and frameworks, as well as moral reasoning, professionalism, and communication skills in practice, strategies, and tools should encompass all 3 domains longitudinally. In general, cognitive skills or knowledge may be evaluated with written or online exams; technical skills can be assessed via simulation or in practice; and behavior skills, more difficult to evaluate, can be assessed via simulation, enacted clinical scenarios, or in practice.50 The ABP guide on Teaching and Assessing Professionalism for Program Directors is a valuable resource, although focuses primarily on professionalism.40 A written or online test may be used as one tool to assess a student’s knowledge in ethics relevant to the practice of neonatology. A test may include True/False questions, multiple-choice questions, essay questions, or a combination of formats. Tests may be used as a formative or summative cognitive assessment, may help identify individual knowledge gaps and areas for improvement, and may also help to guide curricular development. Such tests, however, lack the capacity to assess the student’s application of knowledge, clinical skills or behaviors in practice. Currently, there is no standardized test to assess ethics knowledge in neonatal– perinatal fellows, although our group is in the process of validating one tool for this potential use. Direct clinical observation by supervising attendings can be particularly useful for assessing ethics and professionalism in practice. Such observation can be divided into 2 types described by ten Cate51 as short practice or long practice.17 “Short practice” involves direct observation of the trainee while performing a discrete task in clinical practice, usually lasting 5–15 minutes, such as obtaining informed permission from parents for a procedure, or discussion of withdrawal of life-sustaining interventions with parents. “Long practice” involves direct observation of the fellow in clinical practice over a longer time frame, such as a 24-hour shift or a monthlong rotation. Both types of observations are important in order to assess knowledge and skills, as well as behavior, which occur over time.51 Another assessment strategy for faculty who directly supervise fellows in practice utilizes case-based discussion and inquiry.51 This method prompts the supervising attending to probe the fellow after an otherwise ordinary event in the NICU, such as performing a procedure or having a conversation with a parent, with a theoretical ethical
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dilemma. Questions such as, “What would you have done if you had made an error… ?” or “What if the parent had said… ?” or “What would you do if… ?” This simple yet, effective strategy can help highlight the ethics of everyday clinical practice and assess moral reasoning skills, even without direct observation. As discussed above, simulation can be an effective tool to teach as well as assess ethical and moral reasoning skills, professionalism, and interpersonal and communication skills.33 Simulation provides a safe, non-judgmental environment for fellows to actively participate in high stakes, challenging ethical dilemmas, and difficult conversations.33 Loo et al.52 developed an assessment tool or framework, called the Professionalism Matrix, available through MedEdPORTALs, to analyze professional and unprofessional behaviors in clinical practice. This tool may also be used to teach trainees, and may be used during simulation as well as clinical practice. Peterson et al.53 confirmed the reliability of a modified Gap-Kalamazoo Communication Skills Assessment Form when assessing the communication skills of multidisciplinary learners in simulation, with high internal consistency and high inter-rater reliability. This assessment tool may be useful in evaluating neonatal–perinatal fellows’ communication skills both in simulated environments as well as during direct clinical observation. Another group has published a tool to teach and assess communication skills in the delivery room (Delivery Room Communication Checklist), available through MedEdPORTALs.54 Required rotations for neonatal–perinatal fellows of varying lengths in multiple hospital settings poses even further challenges when attempting to assess ethics and professionalism, interpersonal skills, and communication abilities. The 360-degree evaluation is a tool that can evaluate a trainee’s clinical competence in these areas using data and feedback from multiple key sources within a trainee’s learning environment.49,55 Evaluations can be solicited from the entire interprofessional medical team including “neonatologists, neonatology fellows, pediatric residents, medical students, nurses, neonatal practitioners, respiratory therapists, social workers, and other clinicians who interact with the trainee (e.g., nutritionists and pharmacists),” as well as families.55 The 360-degree assessment tool can help uncover discrepancies between family and staff perspectives regarding professionalism and communication, and “motivate trainees to modify their performance.”55 Self-assessment is crucial to the process of personal growth and improvement. Most trainees are already keenly aware of academic strengths and struggles and able to identify areas for improvement. A 360-degree evaluation should also be completed by the trainee himself/herself. Correlation of an individual learner’s 360-degree assessments and self-assessments, however, may reveal “gaps” or “blind spots, which are clinical behaviors that the trainee is unaware that he or she does or does not do and can consist of hidden strengths or unknown weaknesses.”55 An individualized learning plan (ILP) should be used by all fellows and faculty to aid in the process of self-assessment and self-directed learning, to “identify strengths and weaknesses, formulate learning goals, and track progress” as part of a lifelong learning process.56
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Role of the clinical competency committee The Clinical Competency Committee (CCC) of each neonatal– perinatal training program has been charged with the difficult yet, important task of assessing individual learner’s competencies, milestones, and readiness for independently performing EPAs. This includes assessment of ethical and professional knowledge and skills, as well as relational and communication skills. Several studies have shown that group assessment is superior to individual assessment at uncovering deficiencies in professionalism among students.57,58 It is thus important that the CCC meet as a group to discuss individual fellow performance regularly, as required by the ACGME.
Conclusions and future research There is growing interest in ethics and professionalism education in neonatology, however, evidence-based studies to determine the most effective teaching methods and assessment strategies are still lacking. A “flipped classroom” approach to teaching medical ethics and professionalism in neonatology may be effective, in which students learn course material online via multimedia modules on their own time, then come to class sessions prepared to engage in a variety of educational activities, including in-depth group discussion, enacted role-play, and simulation. This model would engage students with various preferred learning styles, and enable mastery of both knowledge and practical skills in ethics and professionalism during training when time is scarce. Our group is in the process of piloting such an innovative ethics and professionalism curriculum for neonatal–perinatal fellows, as well as developing and validating 2 assessment tools. Outcomes-based research is still needed to determine optimal teaching methods as well as assessment strategies in ethics and professionalism in neonatology to ensure trainees not only achieve competency in these domains, but also to ensure the formation of professional, virtuous clinicians with excellent moral and ethical reasoning skills for the ultimate benefit of the patients and their families.
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