Introduction

Seen as a means of ensuring that “obligations of moral nature which govern the practice of medicine” [1] are maintained, ethics training amongst physicians have evolved to contend with ethical issues facing medical practice. Whilst basic levels of ethics knowledge and skills have been stipulated by accreditation bodies such as The Royal College of Physicians and Surgeons of Canada, The General Medical Council, the American Academy of Family Physicians (AAFP) and the Accreditation Council for Graduate Medical Education (ACGME), many ethics programs have struggled to keep pace with change whilst remaining sensitive to the demands of clinical practice. Inevitable variations in the content and duration of ethics education amongst physicians have been laid bare in a recent review pertaining to family physicians in residency programs in the United States [2].

The litmus test for effectively educating physicians in ethics knowledge, skills and professional conduct in a medical field trepidatious of legal recourse and struggling to meet public trust and societal expectations [3–7] has perhaps been the COVID-19 pandemic. Yet, the surfacing of reports of questionable physician conduct and clinical decisions during the COVID-19 pandemic also offers an opportunity to take stock of prevailing education programs, review gaps in content and structure of ethics education programs as well as update and instil more evidence based, clinically relevant, learner centred education initiatives.

The need for this review

To guide this process of retooling ethics education programs for physicians, a systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature.

Methodology

We adopt Krishna’s systematic evidence-based approach (SEBA) to guide this systematic scoping review (henceforth SSRs in SEBA) [8–14] and scrutinise a broad range of literature [15–17]. With its constructivist perspective and relativist lens, SSRs in SEBA map the complex and diverse historical, socio-cultural, ideological and contextual factors that impact practice to provide a holistic picture of medical ethics training programs for graduates beyond medical school [17–24].

To further improve the reliability of the results, the research team consulted medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore (NUS) and the National Cancer Centre Singapore (NCCS), and local educational experts and clinicians at NCCS, Palliative Care Institute Liverpool, YLLSoM and Duke-NUS Medical School (henceforth the expert team). The Systematic Approach, Split Approach, Jigsaw Perspective, , Funnelling Process, and Discussion stages of SEBA (Fig. 1. The SEBA Process) were used to guide the entire research process.

Fig. 1
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The SEBA process

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Stage 1: Systematic approach

Determining the title and background of the review

The research team consulted the expert team and stakeholders from a local medical ethics training program to determine the overarching goals of the SSR in SEBA as well as the population, context and medical ethics training programs to be evaluated.

Identifying the research question

Guided by the Population, Intervention, Comparison and Outcome (PICOS) elements of the inclusion criteria [25], the primary research question is “How do postgraduate medical training programs teach ethical skills?” The secondary questions are “What are the core topics included?” and “What are the methods used to structure the program in postgraduate training?”

As part of the SEBA methodology’s iterative process, when the initial results of this review were discussed, the expert team advised that a study of current methods of assessing ethics be conducted to address the lack of data on assessments of ethics education. Thus, a second SSR in SEBA was carried out. Similarly guided by PICOS, the primary research question is “How is ethics knowledge, skills, and competencies assessed in postgraduate training?” The secondary question is “What domains are assessed?”

Inclusion criteria

Guided by the expert team, the research team created the inclusion criteria for the SSRs in SEBA for teaching and assessing medical ethics, as outlined (Table 1).

Table 1 PICOS, inclusion criteria and exclusion criteria applied to literature search on medical ethics training programs
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Searching

Overall, both searches involved 16 members of the research team who carried out independent searches of PubMed, Embase, PsycINFO, and ERIC databases for the review. In keeping with Pham, Rajic [26]’s approach to ensuring a viable and sustainable research process, the research team confined the searches to articles published between 1 January 1990 and 31 December 2019 to account for prevailing manpower and time constraints. All research methodologies in articles published in English or had English translations were included. The independent searches were carried out between 14 February 2020 and 9 April 2020. The full PubMed search strategy may be found in Additional File 1.

The research team then independently reviewed all the titles on the final list, compared their individual lists of articles to be included in the review and employed ‘negotiated consensual validation’ to achieve consensus on the final list of articles to be analysed on the teaching of ethics (Fig. 2.) and assessing of ethics (Fig. 3).

Fig. 2
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PRISMA Flow Chart for the Teaching of Ethics

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Fig. 3
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PRISMA Flow chart for the assessing of ethics

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Stage 2: Split approach

For each SSR in SEBA, two teams of five researchers concurrently and independently reviewed the full-text articles in keeping with Krishna’s Split Approach that is focused on enhancing the reliability of the analyses [27, 28]. The first team scrutinised the included articles using Braun and Clarke [29]’s approach to thematic analysis whilst the second team employed Hsieh and Shannon [30]’s approach to directed content analysis. Comparisons between the results of the Split Approach provides method triangulation whilst having each reviewer independently analyse the same data provides investigator triangulation [27, 28]. Triangulation augments external validity and allows this approach to be more objective.

Braun and Clarke (2006)’s approach to thematic analysis

Without an a priori framework for either teaching or assessing medical ethics amongst physicians, we employed Braun and Clarke’s approach to thematic analysis to single out common themes across varying goals and populations of physicians of different grades, experiences and specialties whilst circumnavigating the context-specific nature of medical ethics in Medicine [29, 31–37]. It also accommodates for a wide range of research methodologies present amongst the included articles which prevents the use of statistical pooling and analysis [29, 38–42] and facilitates appropriate analysis of socio-culturally influenced educational processes such as medical ethics.

‘Codes’ were constructed from the ‘surface’ meaning of the text through a reiterative step-by-step thematic analysis. These were re-organised into themes that were best able to represent the data. They were reviewed individually and then as a group. Subsequently, the members of this sub-team deliberated their separate findings online and utilised ‘negotiated consensual validation’ to achieve consensus on the final themes.

Hsieh and Shannon (2005)’s approach to directed content analysis

Hsieh and Shannon’s approach to directed content analysis was employed to increase the validity of the themes and to address Braun and Clarke’s relative failure to engage contradictory data.

With regards to the teaching of ethics, the second sub-team drew codes and categories from Sutton [43]’s article entitled ‘Ethics and law teaching and learning in undergraduate medicine’ and McKneally and Singer [44]’s ‘Bioethics for clinicians 25. Teaching bioethics in the clinical setting’.

With regards to the assessing of ethics, codes and categories from Norcini, Anderson [35]’s ‘Draft 2018 Consensus Framework for Good Assessment’, Veloski, Boex [45]‘s ‘Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7′ and Watling and Ginsburg [46]’s ‘Assessment, feedback and the alchemy of learning’ were used.

These codes were adopted as a framework for reviewing the included articles. Any relevant data not captured by existing codes were assigned a new code through deductive category application. The independent findings were discussed online and ‘negotiated consensual validation’ was again used to achieve consensus on the final ‘code book’.

Stage 3: The jigsaw perspective

The findings of the Split Approach and its reiterative process were then pooled together to ensure a well-rounded perspective of the data. Here, common themes and categories within each SSR were compared. Overlaps between the categories and themes were combined to create a wider perspective of the data, much like bringing together complementary pieces of a jigsaw. This process is called the Jigsaw Perspective and is overseen by the expert team to ensure consistency.

Results

The first search involving the teaching of ethics retrieved 7669 abstracts, with 573 full-text articles reviewed and 66 articles included. Comparison of the categories and themes identified as part of the Split Approach revealed similar categories and themes which were combined into themes/categories using the Jigsaw Perspective. These themes/categories include the goals, content, teaching methods employed, and enablers and barriers to teaching ethics.

For the assessment of ethics, the search saw 9919 abstracts identified, 333 full-text articles reviewed and 29 articles included. The Split Approach from the SSR in SEBA of assessment methods revealed three themes/categories which included the types and domains assessed and the pros and cons of various assessment methods.

Stage 4: The funnelling process

In addition, a third sub-team summarised and tabulated the included full-text articles to ensure that important concepts of discussion and contradictory views within the included articles were retained. The tabulated summaries also serve to verify that the results ascertained are an accurate representation of the existing data. The tabulated summaries for the teaching and assessing of ethics may be found in Additional File 2 and 3 respectively. Under the oversight of the expert team, the research team combined themes/categories from the two SSRs in SEBA based upon their similarities and their areas of overlap in keeping with the Funnelling Process.

The five funnelled themes/categories from the two searches are the goals and objectives, the content, pedagogy, enabling and limiting factors, and assessment tools.

Goals and objectives

The goals and objectives of ethics training programs for doctors are highlighted in Table 2 below.

Table 2 Goals and objectives of ethics training programs
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Overall, the goal of most ethics programs was to refresh key ethical principles covered in medical schools [51], prepare physicians to tackle ethical dilemmas, and improve their confidence in doing so [59, 71, 77]. Some programs also introduced context and specialty-specific ethical dilemmas as highlighted in the next section on content covered [48, 53, 56, 70, 78–80].

Content covered

Content covered is outlined in Table 3.

Table 3 Domains of content covered in ethics training programs
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Most training programs covered a varying number of topics.

Whilst Carrese, Malek [96] noted an overlap in the range of topics covered in ethics training for doctors and those for medical students, the authors explain that “educational materials offered to residents can typically be more complex and contextual than those intended for medical students, and ethical issues can be more nuanced and discussed in greater depth”.

Pedagogy

The diverse pedagogies are highlighted in Table 4 below.

Table 4 Pedagogy employed
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There is great variation in the timing and duration of such training sessions. Formal teaching run by the host organisation or institution tended to come in the form of mandatory training programmes [80, 81] that span the course of a few years [62, 82] or  a single day [67]. Some programs are held over a few hours each year [58, 94], or each month or every few months as part of a wider residency training program [49, 59, 83].

Informal programs tended to be situated in more informal settings where refreshments are served and hierarchies are minimised [49, 59].

Different training programs utilised a combination of approaches to meet their objectives [82]. At the University of Toronto, Howard, McKneally [70] describes integrating formal bioethics teaching with “role modelling of ethical behaviour and bedside teaching around ethical issues”. The impact of this combination is echoed by Lang, Smith [97]’s survey of paediatric programme directors on how ethics is taught. Carrese, Malek [96]’s literature review of medical ethics training similarly highlighted the synergistic nature of the formal, informal and hidden curricula [77].

Other authors have proffered the use of a multidisciplinary approach to illustrate the intricacies of team based working in the healthcare setting [59, 69, 73, 101, 102].

Enabling factors and barriers

Enabling factors and barriers to the successful execution of ethics training programs may present themselves as follows (Table 5):

Table 5 Enabling factors and barriers to ethics training programs
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Believing that new learners often “do not appreciate the practical side of ethical conflicts as they have had limited exposure to clinical medicine or have not yet fully formed a professional identity with its associated values,” Grace and Kirkpatrick [68] piloted ethical vignettes and ethical reasoning technique to acculturate ethical thinking into practice. Howard, McKneally [84]’s study of surgical resident’s attitudes towards ethics teaching revealed a general sense of being poorly prepared and relatively inexperienced for case discussions and practical application of ethical issues.

Carrese, McDonald [60] and Chandra, Ragesh [69] also note that even in the event that ethical issues did arise, they were poorly modelled and rarely used as teaching moments.

Assessment tools

Assessment tools comprise the type of assessment method employed, corresponding domains assessed and their pros and cons (Table 6). These assessment methods may be mapped onto the Miller’s pyramid of clinical competency [131].

Table 6 Types of assessment methods, domains assessed, advantages, disadvantages
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Stage 5: Discussion and synthesis of SSRs in SEBA

A review of the results and consultation with local educationalists, clinicians and researchers experienced in medical ethics teaching and assessment reiterated the completeness of this review. The narrative produced was guided by the STORIES (Structured approach to the Reporting In healthcare education of Evidence Synthesis) statement [38] and Best Evidence Medical Education (BEME) Collaboration guide [39].This novel review of teaching and assessment of ethics amongst physicians reveals a number of insights. Here we list some of the key findings for ease of reference and will delve into three areas of particular interest.

  • The common objective across most ethics programs is to improve awareness of ethical principles and skills in resolving ethical dilemmas tactfully and professionally. More recent articles however focused on changing practice, shaping attitudes and meeting social and professional obligations.

  • Recent accounts of teaching and assessing ethics reveal the impact of context and speciality related influences.

  • The core elements of most programs concerned the four principles of autonomy, beneficence, non-maleficence and justice; the doctor- patient relationship; communication; and end of life care.

  • Speciality or context specific information contents include research ethics; speciality related topics; trainee related considerations and social and or institutional interactions.

  • There were a number of approaches employed to teach ethics yet all were focused upon providing learners with an opportunity to apply their knowledge in a variety of ways, ranging from optional participation in group discussions to guided case discussions and reflections.

  • Factors facilitating ethics education and assessments were a structured program, a nurturing culture and a safe environment to discuss concerns and enquiries.

  • Important in ethics training are role modelling, case-based discussions and instruction on ethical sensitivity and resolving ethical issues.

  • There is a general lack of assessment methods.

While there are inherent differences to each of the training programs, they may be seen to lie on a continuum of guiding the learner from knowledge building to practice and ultimately to nurturing the learner’s professional identity. Indeed, many programs seek to prepare learners for their societal responsibilities [49, 60, 70–76, 85] and their membership to their ‘community of practice’ [69, 70]. This would be consistent with Cruess, Cruess [131]’s “Is” level at the apex of their amended Miller’s pyramid. With this in mind, evidence for this posit is visible from the contents and manner that ethics education is taught.

Careful study of the longitudinal nature of training programs, the presence of refresher sessions and/or sessions involving ‘core’ topics such as autonomy, beneficence, non-maleficence, justice, end of life care,the doctor patient relationship and the duty of care suggests a reinforcement of prevailing knowledge [48, 50, 51, 56, 57, 59, 67, 73, 81, 82, 86, 97, 98]. The introduction of more specialised speciality, clinical and research content suggests a layering of new knowledge and experiential learning. This process of building on prevailing knowledge evidences the longitudinal nature of training that would seem to build on training received in medical school and efforts to deepen appreciation of ethical issues in the clinical setting. This is also evidenced by the methods used to train the learners. Here didactic lectures, online videos and bedside ethics discussions give way to case discussions and presentations, allowing the learner to build their knowledge and confidence and apply their knowledge and skills in addressing the ethical issues [58, 69, 74, 78, 86, 99].

These considerations also highlight the vertical aspect of the spiral curriculum employed by most programs and raise the importance of knowledge and skills assessments. Evidence that ethical training is introduced at specific stages of practice such as during postings where end of life care is especially relevant, or where discussions of withdrawing and withholding life sustaining treatment, such as intensive care placements, suggest horizontal integration of the ethics training programs.

The presence of a spiral curriculum that seeks to build on prevailing knowledge and integrate context specific learning highlights two considerations. The first is the use of pertinent assessments to determine progress to the next stage of the training and the second is the support of the program by the host organizsation.

Training should be followed by assessments to ensure that knowledge has been effectively assimilated and applied appropriately, and to facilitate micro-credentialling, as suggested by Norcini [132]. In tandem with this, there is also the need to establish clear Entrustable Professional Activities (EPA) s in ethics education which, at present, will require further research and consideration given the diversity of practice, specialities, socio-cultural considerations and learner variability in terms of their prevailing knowledge, skills, attitudes and experience [133]. The need for a longitudinal assessment process as a part of an education portfolio and their impact on the development of professional identity formation (PIF) also demands closer scrutiny [131, 134].

Here, learning portfolios will allow seamless integration between ethics training in undergraduate and postgraduate training [51, 83, 97, 98] and would be in keeping with the notion of ethics training being part of a longitudinal training experience [4, 135] that nurtures PIF [131, 134]. Portfolios not only serve as a valuable assessment modality for longitudinal evaluation of ethical competency but also promotes continuous self-learning through the recognition of knowledge deficits while reinforcing good behaviour [63, 136–143].

Yet an effective ethics training program requires support fromresidency programs, healthcare institutes and educational institutes through the allocation ofallocating dedicated resources, manpower and faculty training [64, 70, 79]. The host organisation must orchestrate this training and provide careful oversight of the program's trajectory. Perhaps just as important is that there are efforts to ensure that clinicians acknowledge and adopt their roles and responsibilities in their ‘communities of practice’ [144]. The topics chosen should be practical and feasibly covered within the limited time allotted yet be relevant to clinical practice [52, 55, 59, 60, 73, 79, 83, 96–98].

The programs and host organisations must also instil a nurturing ethical climate through the dissemination of core values and introduction of infrastructure that “proactively incorporates these values in the daily life of the healthcare organi[z]ations” [145]. An ethical climate would aid in professional identity formation [131, 134, 146].

Limitations

Whilst it was our intention to appreciate the range of available literature on ethics education in postgraduate medical education, it is evident that each paper could be studied in greater depth. This limitation is mainly due to incomplete reporting of the current training approaches and their curriculum, as well as the way in which the programs are is carried out and evaluated.

Furthermore, the range of selected articles chosen originates from papers that were largely written in North America and Europe. This limits the applicability of these findings, as the different cultures across the different geographical boundaries are not accounted for.

However, despite these limitations, this scoping review was carried out with the necessary rigour and transparency advocated by Arksey and O’Malley [21], Pham, Rajic [26], and Levac, Colquhoun [147]. The use of Endnote, a bibliographic manager, ensured that all the citations from the different databases were properly accounted for.

Conclusion

We believe the analysis of our findings in this scoping review will be relevant to educators and program designers in postgraduate medical settings around the world. However, the lack of consensus and difference in perspectives regarding the approach, content and quality assessments as well as the need to explore the inherent link amongst ethics, communication and professionalism [63, 148, 149] justifies inclusion of programs focused on enhancing communication skills and professionalism in medicine. In addition, more needs to be done to research on establishing EPAs in ethics amidst the diverse characteristics of learners, their settings and their levels of experience as well as the particular healthcare system and culture that they practice in. Research should also look into portfolio design, implementation and assessment of PIF and micro-credentialling in ethics practice in the postgraduate setting.