Everyday Ethics in the Clinical Practice of Pediatric Residents

1
Everyday Ethics in the Clinical Practice of
Pediatric Residents Margaret Moon, MD, MPH Mark
Hughes, MD, MA Erin McDonald, MPP Holly
Taylor, PhD, MPH Joseph Carrese, MD, MPH Johns
Hopkins Berman Institute of Bioethics, Program on
Ethics in Clinical Practice

• Promoting and Maintaining Best Interest in
  Complex Setting
• Clinical Issue Balance competing medical and
  social demands
• Prescribing sub-optimal medications for
  insurance purposes
• Ethical Challenge Accept limits on care while
  negotiating safety and avoiding harm
• Clinical Issue Responding to unstable home
  settings
• Tailoring care to chaotic home setting,
  homelessness
• Keeping track of children and families lost to
  follow up
• Ethical Challenge Privacy vs. safety, discordant
  life experiences
• Clinical Issue Complex caretaking systems
• Unstable families, unclear familial bonds and
  rights
• Reliance on kinship caretakers who are not legal
  guardians
• Ethical Challenge Law vs. ethics and best
  interests

• CONCLUSIONS
• Observation of interactions between trainees and
  preceptors in an outpatient pediatric setting
  identified ethics issues arising in everyday
  clinical practice of pediatrics.
• These observations may be helpful in defining a
  new taxonomy of everyday ethics.
• Interviews with preceptors identified particular
  issues related to responding to ethics issues as
  they arise.
• LIMITATIONS
• Observations occurred in a single institution
  and involved a predominantly low income, urban
  clinic population. Ethics issues may be
  different in other clinic settings.
• The observations occurred in a teaching setting.
  Private practitioners may encounter a different
  set of issues.
• Observations were limited to interactions
  between residents and preceptors and did not
  include the residents interactions with
  patients. The ethics issues which were
  identified were exclusively those reported by the
  residents.
• IMPLICATIONS
• If ethics-related education fails to address the
  difficult issues actually encountered in everyday
  clinical care, trainees may remain unprepared to
  identify and address these issues satisfactorily.
• Analysis of actual ethics experiences may
  provide a useful basis for ethics-related
  education in residency training.
• More research is needed to identify similarities
  and differences in ethics experiences between
  different clinic and educational settings.

• BACKGROUND
• Little empirical data exist describing the
  ethical dimensions of the everyday clinical
  practice of pediatrics.
• Absence of data limits our ability to assess the
  ethics education needs of pediatric residents.
• The goal of this study was to examine the
  ethical issues that pediatric residents
  encounter as they care for patients and families
  in an outpatient clinical setting.
• Findings from this empirical project will inform
  ongoing ethics education and curriculum
  development in our pediatric residency training
  program.
• METHODS
• Design
• Multi-method, multi-staged qualitative project
• In-depth interviews with residents
• Direct observation of resident-preceptor
  interactions in pediatric outpatient clinic
• In-depth interviews with faculty preceptors
  regarding experiences identifying and managing
  ethics issues in everyday practice
• Data Collection
• 70 hours of direct observation (19 sessions)

• RESULTS
• Content of Observations
• Content analysis of observational data collected
  in this outpatient pediatric teaching clinic
  revealed the following themes regarding ethics
  issues arising in everyday practice
• Ethics Themes
• Promoting and maintaining the childs best
  interests in a complex and resource poor setting
• Responding to requests from external institutions
• Managing relationships with parents, maintaining
  the therapeutic alliance to advocate for the
  child
• Protecting patient privacy and confidentiality
• Managing limits to ones own knowledge and skills
• Preceptor Interviews
• Analysis of preceptor interviews revealed the
  following themes regarding identifying and
  managing ethics issues in clinic
• Difficulty in identifying characteristics of
  ethics in everyday setting

• Responding to Requests from External Institutions
• Clinical Issue School, social services, legal
  system request input from physician
• Letters to avoid eviction, get better housing,
  confirm parental competence
• Ethical Challenge Advocacy for child vs. truth
  telling, justice

• Managing Relationships with Parents
• Clinical Issue Managing parental frustration
  with care
• Limits of medicine, limits of knowledge, beliefs
  about health, clinic system issues
• Angry / combative parents
• Persistently worried parents
• Ethical Challenge Truth telling, preventive
  ethics, impact of culture on health behavior
• Clinical Issue Managing provider frustration
  with parents
• Bad, abusive or dishonest parenting
• Abuse of clinic services
• Ethical Challenge Setting appropriate limits,
  promoting fairness
• Clinical Issue Maintaining a therapeutic
  relationship with parents
• Negotiating with parents so that child is not
  lost to care
• Ethical Challenge Parental autonomy vs. childs
  best interest

• Protecting Privacy and Confidentiality
• Clinical Issue Sharing medical information
  appropriately
• Telephone follow up with unknown callers
• Responding to requests from non-legal guardians
• Ethical Challenge Limits of confidentiality,
  best interests of the child
• Clinical Issue Adolescent privacy and
  confidentiality
• Telephone follow up, parental request for
  information
• Physical exams, requests for same sex provider
• Ethical Challenge Privacy vs. safety,
  sensitivity vs. educational needs

Acknowledgements Dr. Moon received support for
this work from the John and Elaine Freeman
Foundation. Drs. Carrese and Hughes were
supported by the Blaustein Family Foundation.
Dr. Taylor and Ms. McDonald receive support from
the Johns Hopkins Berman Institute of Bioethics
www.bioethicsinstitute.org

• Managing Limits to Own Knowledge and Skills
• Clinical Issue When to ask for help or refuse a
  task
• How to recognize personal limitations, when to
  consult
• Ethical Challenge Role conflict, learner vs.
  provider