WINNIPEG, MAN. Some residency programs have increased efforts to teach ethics to young dermatologists.
At Brown University in Providence, R.I., and the University of Cincinnati, the increased focus on ethics grew out of the personal interests of leaders at both institutions.
The American College of Graduate Medical Education (ACGME) states that residents must meet six general requirements, one of which is professionalism. The ACGME has no specific didactic course work requirements or verification procedures related to professionalism, however, and few dermatology residencies offer much formal training in bioethics or professionalism, said Dr. Lionel Bercovitch of Brown University.
"Those of us in practice, and residents and trainees, encounter ethical issues from the minute we walk into the office to the time we leave," he noted at the annual conference of the Canadian Dermatology Association.
Dr. Bercovitch and his associates, seeking to go beyond issues of industry gifts to physicians, instituted a curriculum in biomedical ethics and professionalism in 2001 that sought to cover a broader range of topics in ethics. (See box.)
They designed it specifically for dermatology trainees, skipping some topics that apply more directly to other specialtiessuch as end-of-life care or euthanasiaand including topics like cosmeceutical dispensing that might not be addressed in conventional medical ethics courses.
Once or twice a month, dermatology residents are required to attend a dinner, funded by the university, to discuss a topic in ethics after reviewing as many as 30 papers or articles related to the topic that are chosen in advance by the course leader and a resident assistant.
"These are not bull sessions. Residents are expected to come and be prepared to defend their views after a review of the literature," Dr. Bercovitch said.
The topic of cosmetic dermatology generated so much interest and debate that it was extended to two sessions.
The lively discussions are key to the seminar's success, said Dr. Katherine Brown, a resident at the university, in a phone interview. "Since you're among close colleagues and friends, you can say what's on your mind and ask questions that, in another forum, you would not feel comfortable to ask," she noted. "It needs to be a discussion, not a lecture. Make sure all of the voices are heard and no one person takes over."
Dr. Priya Zeikus, formerly a resident at Brown and now a Mohs surgery fellow at the Lahey Clinic in Boston, said thatalthough the busy, exhausted residents did not like having to plow through the required reading and attend the ethics sessions after a long workdayit did add to their education by addressing ethical issues not covered in medical school, such as cosmeceutical dispensing.
"Looking back on it, it certainly did raise issues that I didn't think of as ethical issues previously," she said in a phone interview.
Dermatology residents traditionally get a good deal of ethics training, but it does not necessarily occur in a conventional class setting, said Dr. Jorge Garcia-Zuazaga, chair of the American Academy of Dermatology's Residents and Fellows Committee and a resident at Case Western Reserve University Hospital, Cleveland.
At his institution, all dermatology residents are required to complete a 6-hour computer-based lecture series that includes medical ethics, professionalism, and professional conduct.
Also, residents learn the ethics of the profession through the day-to-day role modeling of faculty members; feedback from nurses and clinical support staff; regular evaluations; grand rounds discussions; and journal clubs, he said in a phone interview.
The AAD posts several policies on ethics on its Web site and has compiled principles of professional conduct, Dr. Garcia-Zuazaga added.
Without a more focused effort to discuss ethics, however, many dermatology residents mistakenly assume that, because they are good people, their actions are ethical, said Dr. Diya F. Mutasim, professor and chair of dermatology at the University of Cincinnati.
A discussion at one of his department's annual retreats with its residents moved him to increase teaching around ethics. Residents at the retreat believed one could simply tell who is an ethical person.
"They don't realize ethics is not an either/or thing. It's more complex," he said. "It's something fluid" that relates to situations, not just the person.
He now leads discussions on ethics, professionalism, humanities, and other topics about once a month during the Thursday morning grand rounds time slot. Residents and faculty attend and are asked to have read two or three papers and articles on the topic beforehand.
The residents have taken to it enthusiastically. "Because they're not graded on it, and it's not on board exams, they sit and relax," Dr. Mutasim said.