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Journal of General Internal Medicine

, Volume 15, Issue 7, pp 503–508 | Cite as

Supporting the moral development of medical students

  • William T. BranchJr.
Perspectives

Abstract

Philosophers who studied moral development have found that individuals normally progress rapidly in early adulthood from a conventional stage in which they base behavior on the norms and values of those around them to a more principled stage where they identify and attempt to live by personal moral values. Available data suggest that many medical students, who should be in this transition, show little change in their moral development. Possibly, this relates to perceived pressures to conform to the informal culture of the medical wards. Many students experience considerable internal dissidence as they struggle to accommodate personal values related to empathy, care, and compassion to their clinical training. Educational interventions that positively influence this process have established regular opportunities for critical reflection by the students in small groups. Other interventions include faculty development to enhance role modeling and feedback by clinical faculty. The author espouses more widespread adoption of these educational interventions.

Keywords

Medical Student Moral Reasoning Moral Development Critical Reflection Faculty Development Program 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Branch WT Jr., Hafler JP, Pels RJ. Medical students development of empathic understanding of their patients. Acad Med. 1998;73:361–2.CrossRefGoogle Scholar
  2. 2.
    Odegaard CE. Dear Doctor. A Personal Letter to a Physician. Menlow Park, Calif: Henry J. Kaiser Family Foundation; 1986.Google Scholar
  3. 3.
    Shorter R. Bedside Manners: The Troubled History of Doctors and Patients. New York, NY: Simon and Schuster; 1985.Google Scholar
  4. 4.
    Brice JA. Empathy lost: chronic illness sets a psychiatrist in search of compassion and dignity. Harvard Med Alum Bull. 1986–87;61:28–32.Google Scholar
  5. 5.
    Inglefinger F. Arrogance. N Engl J Med. 1980;303:1507–11.CrossRefGoogle Scholar
  6. 6.
    Ort RS, Ford AB, Liske RE. The doctor-patient relationship as described by physicians and medical students. J Health Hum Behav. 1964;5:25–34.CrossRefGoogle Scholar
  7. 7.
    Branch WT Jr., Pels RJ, Lawrence RS, Arky RA. Becoming a doctor: “critical-incident” reports from third-year medical students. N Engl J Med. 1993;329:1130–2.PubMedCrossRefGoogle Scholar
  8. 8.
    Hupert N, Pels RJ, Branch WT Jr. Learning the art of doctoring: use of critical incident reports. Harvard Student BMJ. 1995;3:99–100.Google Scholar
  9. 9.
    Feudtner C, Christakis DA. Making the rounds. The ethical development of medical students in the context of clinical rotations. Hastings Center Report. 1994;24:6–12.PubMedGoogle Scholar
  10. 10.
    Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68:249–64.PubMedCrossRefGoogle Scholar
  11. 11.
    Self D, Baldwin D. Moral reasoning in medicine. In: JR Rest, ed. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:147–62.Google Scholar
  12. 12.
    Freudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Student’s perceptions of their ethical environmental and personal development. Acad Med. 1994;69:670–9.CrossRefGoogle Scholar
  13. 13.
    Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC. A pilot study of medical student abuse. JAMA. 1990;263:533–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Baldwin DC Jr., Daugherty SR, Eckenfelse EJ. Student perceptions of mistreatment and harassment during medical school: a survey of 10 schools. West J Med. 1991;155:140–5.PubMedGoogle Scholar
  15. 15.
    Reynolds PP. Professionalism in residency. Ann Intern Med. 1991;114:91–2.PubMedGoogle Scholar
  16. 16.
    American College of Physicians Ethics Committee. American College of Physicians Ethics Manual. Third edition. Ann Intern Med. 1992; 117:947–60.Google Scholar
  17. 17.
    Stobo JD, Kohen JJ, Kimball HR, et al. Project Professionalism. Philadephia, Pa: American Board of Internal Medicine; 1995.Google Scholar
  18. 18.
    Branch WT Jr., Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. Teaching medicine as a human experience: a patient-doctor relationship course for faculty and first-year medical students. Ann Intern Med. 1991;114:482–9.PubMedGoogle Scholar
  19. 19.
    Branch WT Jr., Pels RJ, Calkins D, et al. A new educational approach for supporting the professional development of third year medical students. J Gen Intern Med. 1995;10:691–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Mezirow J. How critical reflection triggers transformative learning. In: Mezirow J, ed. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco, Calif: Jossey-Bass; 1990:1–20.Google Scholar
  21. 21.
    Brookfield S. Using critical incidents to explore learner’s assumptions In: Mezirow J, ed. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco, Calif: Jossey-Bass; 1990:177–93.Google Scholar
  22. 22.
    Flanagan JC. The critical incident technique. Psychol Bull. 1954;51:327–58.PubMedCrossRefGoogle Scholar
  23. 23.
    DeWitt DC Jr., Baldwin DC Jr, Daugherty SR, Rowley MD. Unethical and unprofessional conduct observed by residents during their first year of training. Acad Med. 1998;73:1195–200.CrossRefGoogle Scholar
  24. 24.
    Kohlberg L. The Psychology of Moral Development: The Nature and Validity of Moral Stages. San Francisco, Calif: Harper & Row; 1984:170–205.Google Scholar
  25. 25.
    Kohlberg L. The Philosophy of Moral Development: Moral Stages and the Idea of Justice. San Francisco, Calif: Harper & Row; 1981.Google Scholar
  26. 26.
    Gilligan C. In A Different Voice. Psychological Theory and Women’s Development. Cambridge, Mass: Harvard University Press; 1993.Google Scholar
  27. 27.
    Rest J. Background: theory and research. In: Rest JR, ed. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:1–26.Google Scholar
  28. 28.
    Fowler JW. Levels of Faith: The Psychology of Human Development and the Quest for Meaning. San Francisco, Calif: Harper; 1995:69–77.Google Scholar
  29. 29.
    Branch WT Jr. Professional and moral development in medical students: the ethics of caring for patients. Trans Amer Clin Clim Assoc. 1998;109:218–30.Google Scholar
  30. 30.
    Duckett L, Rowan-Boyer M, Ryden MB, Chisham P, Savik K, Rest JR. Challenging misperceptions about nurse’s moral reasoning. Nurs Res. 1992;41:324–31.PubMedCrossRefGoogle Scholar
  31. 31.
    Gilligan C. Remapping the moral domain: new images of self and relationship. In: Gilligan C, Ward JV, Taylor JL, ed. Mapping the Moral Domain. A Contribution of Women’s Thinking to Psychological Theory and Education. Cambridge, Mass: Harvard University Press; 1988:8.Google Scholar
  32. 32.
    Carse AL. The “voice of care”: implications for bioethical education. J Med Philos. 1991;16:5–28.PubMedGoogle Scholar
  33. 33.
    Noddings N. Caring. A Feminine Approach to Ethics and Moral Education. Berkeley, Calif: University of California Press; 1984.Google Scholar
  34. 34.
    Branch WT Jr. The ethics of caring and medical education. Acad Med. 2000;75:127–32.PubMedCrossRefGoogle Scholar
  35. 35.
    Schoen DA. Educating the Reflective Practitioner. San Francisco, Calif: Jossey-Bass; 1987.Google Scholar
  36. 36.
    Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med. 1999;74:800–3.PubMedCrossRefGoogle Scholar
  37. 37.
    Smith CS, Irby DM. The roles of experience and reflection in ambulatory care education. Acad Med. 1997;72:32–5.PubMedGoogle Scholar
  38. 38.
    Sprinthall NA. Counseling and social role taking: promoting moral and ego development. In: Rest JR, ed. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:55–100.Google Scholar
  39. 39.
    Branch WT Jr. Notes of a small-group teacher. J Gen Intern Med. 1991;6:573–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students’ self-awareness, personal growth, and well-being. Acad Med. 1999;74:516–20.PubMedCrossRefGoogle Scholar
  42. 42.
    Yalom ID. The Theory and Practice of Group Psychotherapy. 3rd ed. New York, NY: Basic Books; 1985.Google Scholar
  43. 43.
    Moore GT, Block SD, Briggs-Style C, Mitchell R. The influence of the new pathway curriculum on Harvard medical students. Acad Med. 1994;69:983–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Rest JR, Thomas S. Educational programs and interventions. In: Rest JR, ed. Moral Development: Advances in Research and Theory. New York, NY: Praeger; 1986: 59–88.Google Scholar
  45. 45.
    DeHaan R, Hanford R, Kinlaw K, Philler D, Snarey J. Promoting ethical reasoning, affect and behavior among high school students: an evaluation of three teaching strategies. J Moral Ed. 1997;26:5–20.Google Scholar
  46. 46.
    Self DJ, Olivarez M, Baldwin DC Jr. Clarifying the relationship of medical education and moral development. Acad Med. 1998;73:517–20.PubMedCrossRefGoogle Scholar
  47. 47.
    Self DJ, Olivarez M, Baldwin DC Jr. The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students. Acad Med. 1998;73:521–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Barnard D, Clouser KD. Teaching medical ethics in its contexts: Penn State College of Medicine. Acad Med. 1989;64:745–51.CrossRefGoogle Scholar
  49. 49.
    Evans BJ, Stanley RO, Mestrovic R, Rose L. Effects of communication skills training on student’ diagnostic efficiency. Med Educat. 1991;25:517–26.CrossRefGoogle Scholar
  50. 50.
    Smith R, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Intern Med. 1998;128:118–26.PubMedGoogle Scholar
  51. 51.
    Ambrozy D, Irby D, Bowen J, Burack J, Carline J, Stritter F. Role model’s perceptions of themselves and their influence on student’s specialty choices. Acad Med. 1997;72:1119–21.PubMedCrossRefGoogle Scholar
  52. 52.
    Wright S. Examining what residents look for in their role models. Acad Med. 1996;71:290–92.PubMedCrossRefGoogle Scholar
  53. 53.
    Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med. 1997;12:53–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Reuler J, Nardone D. Role modeling in medical education. West J Med. 1994;161:335–7.Google Scholar
  55. 55.
    Wright S, Kern D, Kolodner K, Howard D, Brancati F. Attributes of excellent attending-physician role models. New Engl J Med. 1998;339:1986–93.PubMedCrossRefGoogle Scholar
  56. 56.
    Takayama M, O’Neil E. Insights into medical students’ career choices based on third- and fourth-year students’ focus-group discussions. Acad Med. 1997;72:635–40.PubMedCrossRefGoogle Scholar
  57. 57.
    Burack JH, Irby DM, Carline JD, Root RK, Larsen EB. Teaching compassion and respect. Attending physician’s responses to problematic behaviors. J Gen Intern Med. 1999;14:49–55.PubMedCrossRefGoogle Scholar
  58. 58.
    Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73:387–96.PubMedCrossRefGoogle Scholar
  59. 59.
    Ende J. Feedback in clinical medical education. JAMA. 1983;250:777–81.PubMedCrossRefGoogle Scholar
  60. 60.
    Hafferty F. Characteristics of the informal curriculum and trainee’s ethical choices. Acad Med. 1996;71:629–30.Google Scholar
  61. 61.
    Hundert EM. Characteristics of the informal curriculum and trainee’s ethical choices. Acad Med. 1996;71:624–33.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2000

Authors and Affiliations

  • William T. BranchJr.
    • 1
  1. 1.Division of General MedicineEmory University School of MedicineAtlanta

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