Background: Little is known about the ethical issues confronting medical students during their first exposure to emergency medicine (EM). The aim of this study was to review student narratives for insight into ethical situations and the impact they might have on our students as they adapt to the clinical world.
Methods: This was a prospective observational study of first and second-year medical students, completing an EM clerkship at three university-affiliated hospitals between 2014-2017. During the study period, medical students were asked to write a short narrative description of three cases that had the greatest impact on them. The students were blinded to the study objectives. Each narrative essay was deindentified and independently analyzed by three EM investigators. Our coding system and data abstraction for ethical incidents was adapted from a national classification scheme. Descriptive statistics were used to summarize the data. The inter-rater agreement for coding these student essays was determined using kappa statistics.
Results: During the four-year study period, 292 consecutive student essays were evaluated from 103 medical students. Interrater reliability was moderate, with a median kappa statistic of 0.65. A total of 194 specific incidents were coded across 20 categories of ethical standards. Common categories were incidents related to: access to and equity in healthcare (16.5%); consent (10.8%); miscommunication (9.3%); death and dying (8.8%); and the right to refuse treatment (8.8%). Overall, 74.2% (144/194) were depictions of exemplary instances of ethical issues, 13.9% (27/194) were considered normal interactions, and 11.9% (23/194) were categorized as unethical behavior. While students were impressed by their observations of EM physicians and staff, their eyes were opened to the improper treatment of acutely ill patients, be it poor pain management, discrimination, inadequate education, or a perceived lack of empathy
Conclusion: Drawn from daily experience, student reflections provided insight into learning not easily measured by traditional evaluation. Analysis of these cases reveals that many interactions are intimately tied to the student’s unique role on the medical health care team, and how that role can lead to ethical compromise.