title: Everyday ethics in internal medicine resident clinic: an opportunity to teach.
abstract: OBJECTIVE
  Being a good doctor requires competency in ethics. Accordingly, ethics education during residency training is important. We studied the everyday ethics-related issues (i.e. ordinary ethics issues commonly faced) that internal medical residents encounter in their out-patient clinic and determined whether teaching about these issues occurred during faculty preceptor-resident interactions.
  
  
  METHODS
  This study involved a multi-method qualitative research design combining observation of preceptor-resident discussions with preceptor interviews. The study was conducted in two different internal medicine training programme clinics over a 2-week period in June 2007. Fifty-three residents and 19 preceptors were observed, and 10 preceptors were interviewed. Transcripts of observer field notes and faculty interviews were carefully analysed. The analysis identified several themes of everyday ethics issues and determined whether preceptors identified and taught about these issues.
  
  
  RESULTS
  Everyday ethics content was considered present in 109 (81%) of the 135 observed case presentations. Three major thematic domains and associated sub-themes related to everyday ethics issues were identified, concerning: (i) the Doctor-Patient Interaction (relationships; communication; shared decision making); (ii) the Resident as Learner (developmental issues; challenges and conflicts associated with training; relationships with colleagues and mentors; interactions with the preceptor), and; (iii) the Doctor-System Interaction (financial issues; doctor-system issues; external influences; doctor frustration related to system issues). Everyday ethics issues were explicitly identified by preceptors (without teaching) in 18 of 109 cases (17%); explicit identification and teaching occurred in only 13 cases (12%).
  
  
  CONCLUSIONS
  In this study a variety of everyday ethics issues were frequently encountered as residents cared for patients. Yet, faculty preceptors infrequently explicitly identified or taught these issues during their interactions with residents. Ethics education is important and residents may regard teaching about the ethics-related issues they actually encounter to be highly relevant. A better understanding of the barriers to teaching is needed in order to promote education about everyday ethics in the out-patient setting.
authors.affiliation: Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA. jcarrese@jhmi.edu
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Carrese
authors.forename: Erin L
authors.initials: EL
authors.lastname: McDonald
authors.forename: Margaret
authors.initials: M
authors.lastname: Moon
authors.forename: Holly A
authors.initials: HA
authors.lastname: Taylor
authors.forename: Kiran
authors.initials: K
authors.lastname: Khaira
authors.forename: Mary
authors.initials: M
authors.lastname: Catherine Beach
authors.forename: Mark T
authors.initials: MT
authors.lastname: Hughes
mesh_terms: D004992:Ethics, Medical / Q000193:education*; D006801:Humans; D007388:Internal Medicine / Q000193:education* / Q000941:ethics; D007396:Internship and Residency / Q000379:methods*; D010044:Outpatient Clinics, Hospital / Q000941:ethics; D010817:Physician-Patient Relations / Q000941:ethics; D011231:Preceptorship / Q000379:methods