title: Teaching ethics to paediatrics residents: the centrality of the therapeutic alliance.
abstract: BACKGROUND
  Previous research on ethical issues encountered by medical professionals in training and practice have presented the thematic content of the cases they encounter rather than the activities in which clinicians engage and in which they most often encounter ethical issues. We conducted a direct observation study of paediatrics residents and their preceptors seeing patients in an out-patient general paediatrics clinic. Our objectives were to describe the everyday ethics-related issues paediatrics residents encounter as they interact with patients. Our ultimate goal is to use this knowledge to enhance current efforts to teach ethics to paediatrics residents.
  
  
  METHODS
  The study team directly observed paediatrics residents discussing patients with their faculty preceptors (19 half-day sessions, 76 hours) in an out-patient general paediatrics clinic located in an urban academic medical centre. Each interaction between resident and preceptor about a single patient was considered a case for further analysis.
  
  
  RESULTS
  A total of 247 cases were recorded. Forty-one of the cases were coded as having ethics-related content. A constant comparative method of qualitative data analysis revealed that residents were most likely to encounter ethical issues when engaged in the following activities: (i) maintaining a therapeutic alliance with the caregiver (e.g. the parent); (ii) prioritising patient or family needs; (iii) adjusting to the power embodied by the role of doctors, and (iv) distinguishing suboptimal care from abuse or neglect. In addition, our findings indicate that it is through their efforts to maintain the therapeutic alliance with the caregivers of their patients that residents engage in and integrate three processes: developing their medical knowledge; adhering to professional norms, and balancing the power inherent in the doctor's role with their responsibility to serve the patient's interests.
  
  
  CONCLUSIONS
  Medical faculty tasked with teaching ethics to paediatrics residents can utilise the results of this project to better target and enhance their ethics education efforts directed at residents in the out-patient setting. Future research could further examine and test these findings in other clinical settings (e.g. adult general medicine).
authors.affiliation: Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA. htaylor@jhsph.edu
authors.forename: Holly A
authors.initials: HA
authors.lastname: Taylor
authors.forename: Erin L
authors.initials: EL
authors.lastname: McDonald
authors.forename: Margaret
authors.initials: M
authors.lastname: Moon
authors.forename: Mark T
authors.initials: MT
authors.lastname: Hughes
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Carrese
mesh_terms: D000328:Adult; D002648:Child; D002983:Clinical Competence / Q000592:standards*; D004645:Empathy; D004992:Ethics, Medical / Q000193:education*; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008396:Maryland; D010372:Pediatrics / Q000193:education*; D010817:Physician-Patient Relations; D013663:Teaching / Q000379:methods*