On-the-Job Ethics – Proximity Morality Forming in Medical School: A grounded theory analysis using survey data...

Hans O. Thulesius, MD, Ph.D. Abstract On-the-job-ethics exist in all businesses and can also be called proximity morality forming. In this paper we propose that medical students take a proximity morality stance towards ethics education at medical school. This means that they want to form physician morality “on the job” instead of being taught ethics like any other subject. On-the-job-ethics for medical students involves learning ethics that is used when practicing ethics. Learning ethics includes comprehensive ethics courses in which quality lectures provide ethics grammar useful for the ethics practicing in attitude exercises and vignette reflections in tutored group discussions. On-the-job-ethics develops professional identity, handles diversity of religious and existential worldviews, trains students described as ethically naive, processes difficult clinical experiences, and desists negative role modeling from physicians in clinical or teaching situations. This grounded theory analysis was made from a questionnaire survey on attitudes to ethics education with 409 Swedish medical students participating. We analyzed over 8000 words of open-ended responses and multiplechoice questions using classic grounded theory procedures, but also compared questionnaire data using statistics such as multiple regression models. The paper gives an example of how grounded theory can be used with a limited amount of survey data. Background Medical ethics is different from other subjects taught at medical school and the importance of formal ethics courses has been questioned (Hafferty & Franks, 1994). Some medical schools combine instruction in bioethical principles with teaching of humanities programs (Andre, Brody, Fleck, Thomason & Tomlinson, 2003). The teaching of ethics varies in Swedish medical schools from interspersed lectures to formal ethics courses. We designed a questionnaire survey in order to elucidate how Swedish medical students view the ethics education in medical schools (Thulesius, Sallin, Lynöe & Löfmark, 2007; Lynöe, Löfmark & Thulesius, 2008). Many students gave input to the ethics course curriculum: Should ethics be taught in lectures or learned through group discussions? Should the ethics course be a separate course among others, or should it be part of other courses with lectures and group discussions interspersed? Should it come early or late in the medical school curriculum? Should the literature be specific ethics literature or novels and short stories with relevant ethical content? From multiple-choice responses we found that strong ethics interest was associated with frequent experiences of physician teachers as good role models and an absence of poor role models (Lynöe et al., 2008). In the present study we wanted to explore what was going on in medical schools regarding the medical ethics education by analyzing open-ended survey responses together with response data from multiplechoice items. Method We constructed a survey on attitudes towards the medical ethics education during 2005 as a request from the delegation of medical ethics of the Swedish Society of Medicine. Swedish medical students from the 1st, 5th and 11th (last) term participated. The survey consisted of 14 items, of which 10 had a total of 59 multiple-choice response options and generous space for open-ended comments, and 4 items were open-ended only, see Table 1. The overall response rate to the questionnaire survey was 36%, and varied between different centers from 13% to 83%, with a total of 409 respondents, 308 women (75%) and 101 men (25%). More than half (220/409) of the respondents gave one or more written open comments amounting to >8000 words. These comments were transcribed into Word from handwritten text. “Walking survey” data from informal interviews with four physicians, of which two has been teaching medical ethics at...

Unprivatizing: A bridge to learning

Virginia Leigh Hamilton Crowe, RN, MS, Ed.D. Jeanne Ellen Bitterman , MA, MA, Ed.D. Abstract Depression is a complicated condition situated in a cultural environment that often impedes learning. The purpose of this grounded theory study was to better understand depression from the perspective of those who are living with depression. Data were collected from many sources including document review and autobiographical literature; however, the primary data were collected through in-depth interviews. Fifteen individuals, thirteen women and two men, who felt they had learned both about and from their depression volunteered to participate in the primary interview process. Analysis of the data generated categories, properties and the core concept of unprivatizing. Through theoretical coding a process of learning about one’s depression emerged which suggests that learning about one’s depression can be experienced as a transitional and meaningmaking process that occurs over an extended period of time and facilitates development. Background The disease of depression remains a great mystery. It has yielded its secrets to science far more reluctantly than many of the other major ills besetting us. (Styron, 1990, p. 11) Depression, or depressive illness, is often referred to as a constellation of disorders that depict a condition or disease which disrupts a person’s mood, behavior, physical well-being, and thought (National Institute of Mental Health Depression Brochure, 2000; O’Connor, 1997; Thompson, 1996). Depressive illness is most often attributed to a complex interaction between physiological, psychological, and sociocultural factors (Mazure, Keita, & Blehar, 2002; Murthy, 2001; Surgeon General’s Report on Mental Health, 1999). Depression is not a rare phenomenon nor is it without significant cost. According to the National Institute of Mental Health (NIMH) (2000), in any given 1-year period, 9.5% of the population will suffer from a depressive illness. The World Health Organization (WHO) notes that major depression presents the greatest burden of disease for women and is a leading cause of disability globally for both males and females (Lopez et al., 2006; Murthy, 2001). In the United States, Major Depressive Disorder (MDD) is a leading cause of disability and produces one of the highest medical costs of all behavioral conditions (Goldman, Nielson, & Champion, 1999; Hasin, Goodwin, Stinson, & Grant, 2005). It is most difficult to calculate the significant personal and family costs associated with depressive illness, specifically given that one of the most indefinable and devastating of these costs is suicide (Dumais et al., 2005; Goldman, Nielson, & Champion, 1999). The Surgeon General’s Report on Mental Health (1999) states that more than 80% of people with depression can be treated successfully with medication, mental health therapy or a combination of both (Goldman, Nielson, & Champion, 1999; Mazure, Keita, & Blehar, 2002; Murthy, 2001; O’Connor, 1997). The difficulties dealing with depression include the underdiagnosis and cultural stigma associated with mental illness; the complex interaction between physiological, psychological, and sociocultural factors; and the numerous yet often elusive and compounding contributors and triggers to depressive episodes. Thus, to become aware of, acknowledge, and continue learning about depression and how it interacts with one’s life are daunting tasks (Beck, Tush, Shaw, & Emery, 1979; Burns, 1999; O’Connor, 1997). And while much is known about what the experts believe is important to teach the depressed individual (Beck, Tush, Shaw, & Emery 1979; Burns, 1999; O’Connor, 1997), little is known or understood about the essential process of learning about depression from the perspective of those living with and learning about their own depression. The purpose of this study was to explore the experiences...