Implementation and evaluation of a near-peer-facilitated medical ethics curriculum for first-year medical students: a pilot study

Abstract

Introduction

The primary objectives of this study were to implement a novel near-peer-facilitated case-based medical ethics curriculum intended for the audience of a large cohort of first-year medical students (n = 193) and to objectively evaluate the immediate efficacy of the curriculum based on pre- and post-session survey responses to ethical quandaries.

Methods

Two near-peer-facilitated medical ethics case discussion sessions were included in the first-year curriculum during the 2017–2018 academic year. The sessions were designed and led by second-year medical student facilitators under the direction of a faculty mentor and were presented as a year-long curricular thread. First-year students were asked to complete pre- and post-session surveys with ethical questions relevant to each case and session. Students were additionally asked to measure the contribution of discussion sessions to their development as a future physician.

Results

Post-session survey results showed that students had a better understanding of specific ethical issues immediately following discussion sessions (p<0.0001). Over three-quarters of students indicated that the near-peer-led medical ethics case discussions contributed somewhat or very much to their development as a future physician. Anecdotal feedback from second-year medical students also suggested that their involvement as facilitators was beneficial to their educational development.

Conclusion

Near-peer-facilitated case discussions were an effective strategy for teaching medical ethics to first-year medical students with demonstrated objective improvements in ethical decision-making. Additionally, near-peer discussions of ethical cases and principles with first-year medical students aided in subjective measures of professional development.

Introduction

Medical ethics educators have endorsed ideal approaches to teaching undergraduate medical ethics utilizing cases commonly encountered in everyday clinical practice, taught at a level appropriate for the intended learners [1–3]. Undergraduate ethics education can fail learners in the preclinical years if there is too much focus on sensational cases that are difficult to resolve or when educational content seems irrelevant due to a limited exposure to clinical medicine and/or falls outside of their current “basic science”-focused learning paradigm [3]. Teaching cases may also fail to develop the critical thinking skills necessary to evaluate and resolve “real-world” ethics cases if focused on overly simplistic approaches to clinical ethics consultation, i.e., attempting to resolve all archetypal clinical ethics quandaries of the practicing physician exclusively utilizing a singular approach to ethics consultation (e.g., Beauchamp and Childress’ “Four Principles” [4]). To overcome such limitations in undergraduate medical ethics education, enthusiasm is growing for the utilization of near-peer educators better able to deliver relevant content at a level appropriate to their peers with a focus on more practical approaches to resolving clinical ethical dilemmas [5, 6].

Prior studies that have evaluated the use of near-peer teaching in medical education have shown improved student classroom participation and discussion, improved cultivation of moral clinical reasoning and critical thinking skills, and improved student interest in learning bioethics [7–12]. A recent review of peer-led teaching in undergraduate medical ethics education highlighted the growing consensus that near-peer teaching may be an ideal method for teaching medical ethics to undergraduate medical students and demonstrated superiority to other methods in terms of efficacy and student satisfaction [6]. Unfortunately, there is a relative paucity of studies exploring this educational pedagogy and the need for more objective measurements of learning outcomes for this approach [6].

With an aim of enriching medical ethics education in the undergraduate medical educational curriculum at our institution, we expanded our medical ethics curriculum for first-year medical students by developing an integrated, pilot program that utilized case-based bioethics discussions led by second-year medical student near-peer facilitators, with focus on ethical issues that were relatable to the clinical knowledge base and experience of most first-year medical students. The goal was to promote knowledge and awareness of ethical issues pertinent to first-year medical students and improve the way in which students develop their own moral and ethical identity, as well as the manner in which students perceive and respond to the differing views of their peers. The primary objectives of this study were to implement the novel near-peer-facilitated case-based medical ethics curriculum for a large cohort of first-year medical students and to objectively evaluate the immediate efficacy of the curriculum on student learning outcomes based on pre- and post-session survey responses to ethical quandaries. The secondary objective was to assess medical student satisfaction with the pilot curriculum.

Methods

Study Design

This pilot survey-based study was designed to assess the immediate efficacy of the novel medical ethics curriculum redesign at the Medical College of Georgia (MCG) at Augusta University for the 2017–2018 academic year. The Augusta University Institutional Review Board evaluated this study and deemed it appropriate for exemption. Survey questionnaires completed during this study were voluntary and not used for academic credit.

Subjects and Facilitators

Survey respondents were first-year medical students (n = 193) enrolled at MCG during the 2017–2018 academic year. At the beginning of the academic year, students participated in a 3-day Art of Doctoring module that includes an introduction to medical professionalism, communication, and medical ethics. The pilot near-peer-facilitated case-based medical ethics sessions continued this medical ethics curricular thread throughout the year.

To showcase role modeling, enhance student discussion participation, and encourage professional discussion of multiple viewpoints, the case-based sessions were designed and facilitated by a small group of second-year medical students under the guidance of the Chief of the Division of Bioethics, who served as the clinical faculty mentor. The learning materials for each case-based discussion session were created by the second-year medical student facilitators and approved by the clinical faculty mentor. Additionally, preparation for each session was conducted among the near-peer facilitators with the clinical faculty mentor to review case material and discuss appropriate responses to the proposed discussion questions. Concerns for potential lack of content knowledge and limited ethical expertise of second-year medical student near-peer-facilitators were addressed by encouraging near-peer-facilitators to acknowledge any areas of uncertainty openly and with transparency during classroom discussion.

All materials for the session including the journal articles, survey questions, learning objectives, and discussion questions (as detailed in the Curriculum subsection) were designed by the second-year near-peer facilitators and provided to the first-year medical student class to review prior to the sessions. The clinical faculty mentor was present at each session to serve as a resource only if questions arose that were difficult for near-peer-facilitators to answer, but the clinical faculty mentor was not intended to offer clinical experience or expertise during the discussion.

Curricular Model

The novel near-peer-facilitated case-based medical ethics curriculum included two medical ethics case discussion sessions. Each of the two medical ethics case discussion sessions lasted 2 h, and two cases were presented during each session (one per hour) with mandatory attendance. The near-peer facilitators led the entire discussion sessions. Prior to each session, all first-year medical students were required to review a provided journal article relevant to the upcoming session and then complete a pre-session survey that included 2–4 multiple-choice questions related to each case topic. At the beginning of each case, the second-year medical student facilitators presented a short, introductory overview that included relevant terminology and background of the medical ethics topic to be discussed. The goal of the overview was to introduce the topic to students and provide a baseline level of factual knowledge to allow students to address the cases from a similar level of understanding.

After the case overview, the entire class of first-year medical students was divided into small groups of 5–6 students to talk about each case and the discussion questions, which were available prior to the session and presented on an overhead screen during the class. Students were encouraged to choose how they would like to direct their own discussion based on small group dynamics and where their group discussion led them. Following the small group discussion, there was an interactive discussion with the entire class lead by second-year near-peer facilitators with a goal of promoting respect for differing viewpoints among peers and allowing thoughtful responses to peers in a non-threating environment. After the session ended, students were asked to complete a post-session survey with questions and responses identical to the pre-session survey. The students were not assessed or graded during any part of the sessions. A summary of the structural format of each medical ethics case discussion is presented in Table 1, and an outline of the medical ethics case descriptions is provided in Table 2. An expanded description of case learning objectives and discussion questions are provided in Appendix.

Table 1.

Medical ethics case discussion session format breakdown

Time allotted	Session component
5 min	Facilitator introductions
10–15 min	Introductory overview and case presentation
15–20 min	Small group discussion
20 min	Large group discussion
5 min	Concluding remarks

Table 2.

Medical ethics case discussion description outlines for academic year 2017–2018

Session 1 (case 1): biospecimens and HeLa cells

Case description

Implications of the discovery of HeLa cells on modern scientific technology and medical discovery including topics of informed consent, health disparities, and ownership of biospecimens

Session 1 (case 2): clinical research and genetic information

Case description

Current ethical implications of modern genetic information advancements including topics of clinical research ethics, the Common Rule, informed consent, risk-benefit ratio, and respect for subjects

Session 2 (case 3): advanced reproductive technologies and surrogacy

Case description

Historical timeline and background of advanced reproductive technologies (ART) with topics including the ethical, professional, and social considerations involving surrogacy and in vitro fertilization (IVF)

Session 2 (case 4): genetic modification of human embryos

Case description

Current ethical considerations and recent regulation developments at the provider and societal level surrounding modern gene modification including topics of CRISPR/CAS9 and mitochondrial transfer therapy

Survey Questionnaire and Data Collection

Attendance was recorded via Turning Point© audience response system. While attendance and review of the journal article, learning objectives, and discussion questions were mandatory for each medical ethics case discussion session, the pre-session and post-session surveys were not mandatory and not associated with course credit. However, students were encouraged to complete the surveys for each session, which were administered by the institutional learning management system, Brightspace Desire 2 Learn© (D2L).

Survey questions included two to four multiple-choice questions related to each case topic that were designed by near-peer facilitators to incorporate common medical ethics topics relevant to the knowledge of a first-year medical students including principles of informed consent, protected patient information, clinical research ethics, and physician bias. Pre-session surveys were opened for responses at least 2 days prior to the sessions, and identical post-session surveys were available to responses immediately after and up to 24 h after the sessions. Appropriate responses to the pre-session and post-session survey questions were identified by the session facilitators and approved by general consensus of trained physician-ethicists and members of the hospital ethics committee. A final review was done by the Chief of the Division of Bioethics. Survey answer choices were determined to be “appropriate” or “inappropriate” responses based on explicit knowledge of common ethical principles with general consensus across the literature, avoiding vague questions or answer choices without a straightforward ethical answer. Students could choose multiple responses for each question based on their perceptions of the bioethical issue presented and how they might best handle the clinical scenario, and multiple “appropriate” answer choices were allowed for majority of the survey questions. Each post-session survey question set included an additional question, “The student led Ethics Case Discussion Sessions contributed to my development as a future physician,” which students recorded on a four-point scale from “Not at All” to “Very Much.”

Data Analysis

Student responses to identical pre-session and post-session survey questions were coded to maintain anonymity and then examined to determine the utility of case-based discussion sessions by analysis of whether student perspectives on the ethical issues changed as an immediate result of classroom discussion. The coded pre-session and post-session survey data was paired for each individual student response and analyzed using IBM SPSS Statistics V25 by a statistician that was not part of the research study [13]. All statistical analyses were conducted at a significance level of alpha = 0.05.

For each participant, the total number of appropriate and inappropriate responses were totaled by each case and session. The percentage of appropriate responses were then calculated and recorded for each participant by case and session. Paired t tests were used to analyze the change in percentage appropriate responses for each participant from pre- to post-session answers by case and session. If a participant did not complete both the pre- and post-survey for a session, they were excluded from the analyses for that session. Participants from sessions 1 and 2 were then pooled to look at combined overall results. A paired t test was performed to determine whether there was a significant difference in percent appropriate responses once the two sessions were combined. A participant could technically be included twice, once for session 1 and once for session 2 in this analysis. For the additional question on contribution to physician development on each post-session survey, student responses were reported on a four-point scale from Not at All to Very Much and were analyzed and displayed using GraphPad Prism 8^TM.

Results

The overall percentage of students in the first-year medical class (n = 193) who completed the pre-session and post-session surveys during the 2017–2018 academic year is shown in Table 3. Of those, 150 and 155 students completed both the pre- and post-session surveys for sessions 1 and 2, respectively.

Table 3.

First-year medical class (n = 193) response rates among identical pre- and post-session medical ethics surveys during the 2017–2018 academic year

	Pre-session survey respondents	Post-Session survey respondents
Session 1	88.1% (n = 170)	88.1% (n = 170)
Session 2	92.2% (n = 178)	86.0% (n = 166)

The mean percentage of appropriate answers from an identical post-session survey was significantly increased from pre-session survey responses for cases 1 (p < 0.0001), 2 (p = 0.0473), and 3 (p = 0.0003) as well as sessions 1 (p < 0.0001) and 2 (p = 0.0191) overall. In total of all four case-based discussions, students scored a combined average of 87.3% [CI 85.4–89.1] appropriate answers on the post-session surveys, which was a significant increase from a combined average of 79.7% [CI 77.8–81.6] appropriate answers on the pre-session surveys (p < 0.0001). A breakdown of mean percentage of appropriate answers is shown in Tables 4 and 5 by each case and discussion session, respectively.

Table 4.

Mean percentage of appropriate responses by each case in identical pre- versus post-session medical ethics surveys administered to the first-year medical class (n = 193) based on paired t test analysis with reported p values

	Pre-session survey mean percentage of appropriate answers (%) [CI]	Post-session survey mean percentage of appropriate answers (%) [CI]	p value
Session 1 (case 1): Biospecimens and HeLa cells (4 survey questions) (n = 150)	66.8 [63.2–70.5]	87.3 [84.1–90.5]	< 0.0001
Session 1 (case 2): Clinical research and genetic info (4 survey questions) (n = 150)	85.0 [81.6–88.4]	88.3 [85.2–91.5]	0.0473
Session 2 (case 3): Advanced reproductive tech (3 survey questions) (n = 155)	76.1 [72.6–79.7]	83.2 [79.8–86.7]	0.0003
Session 2 (case 4): Genetic modification of human embryos (2 survey questions) (n = 155)	91.9 [88.4–95.5]	94.2 [91.5–96.9]	0.1622

Table 5.

Mean percentage of appropriate responses by each session and combined overall in pre- versus post-session ethics surveys administered to the first-year medical class (n = 193) based on paired t test analysis with reported p values

	Pre-session survey mean percentage of appropriate answers (%) [CI]	Post-session survey mean percentage of appropriate answers (%) [CI]	p value
Session 1 overall (n = 150)	75.9 [73.3–78.5]	87.8 [85.4–90.2]	< 0.0001
Session 2 overall (n = 155)	83.4 [80.7–86.0]	86.7 [83.8–89.6]	0.0191
Combined sessions 1 and 2 (n = 305)	79.7 [77.8–81.6]	87.3 [85.4–89.1]	< 0.0001

At the end of each session, respondents were asked in the post-session survey to rate the extent to which each near-peer-led case-based discussion session contributed to their development as a physician. Individual results from each session are displayed in Fig. 1, with 78.2% and 82.5% of total respondents from session 1 (n = 170) and session 2 (n = 166), respectively, indicating that the near-peer-led case discussion sessions contributed at least somewhat to their development as a future physician.

Fig. 1.

Post-session rating of case-based discussions for a session 1 (n = 170) and b session 2 (n = 166) on contribution to development as a future physician based on a four-point scale

Discussion

Administration of the pre- and post-session surveys with questions related to each ethics case discussion served a purpose that was twofold. First, we were able to evaluate the effectiveness of each case-based medical ethics discussion session by assessing the percentage of appropriate and inappropriate responses to common ethical scenarios for each student before and after classroom discussion. Secondly, the survey administration also encouraged students to come to class prepared, having already thought about and developed their own personal perspectives on the ethical scenarios to be discussed further in a group setting. It is important to point out that the survey questions were based on basic principles of medical ethics with which the first-year medial students had some familiarity. By analyzing individual student responses in identical pre- versus post-session surveys, the significant increase in mean percentage of appropriate answers from all session combined from 79.7% [CI 77.8–81.6] to 87.3% [CI 85.4–89.1] on the post-session surveys (p < 0.0001) is substantial and provides a promising indication that the near-peer-led case-based discussion promoted immediate awareness and improved student knowledge about the specific medical ethics scenarios presented.

The final case about Genetic Modification of Human Embryos did not show a significant change in survey responses before and after the discussion, which may be due to the lack of expert consensus about the topic or flaws in the case design and/or pre- and post-session questions. In future discussion sessions, responses from this medical ethics topic may be better assessed by developing more objective survey questions based on explicit medical ethical principles surrounding genetic modification and surrogacy.

A 2015 narrative review by Hindmarch et al. focusing on peer-based ethics education, reported a general consensus that near-peer ethics education appears to be superior to traditional didactic teaching methods [6]. Significant gaps in the literature were shown though, including that a majority of studies reported subjective analyses of student-reported levels of participation, efficacy, and satisfaction with the curriculum rather than objective analyses of student learning outcomes [6]. The limited studies that reported objective measurements of student learning outcomes have been promising, however, suggesting that near-peer discussion of medical ethics facilitates significant improvements in moral judgement and growth [14], principled cognitive moral thinking [15], and discrimination abilities for recognizing ethical dilemmas [16].

Despite historical challenges of allocating course hours between medical knowledge-focused competencies and other competencies for physician development such as medical ethics and professionalism [10], it was most encouraging to find that over 75% of the class surveyed in our study found the medical ethics case discussions contributed to their development as a future physician. This data supports both the utility of the case-based discussion format and the near-peer-facilitated pedagogical approach. In addition, informal and anecdotal feedback from second-year medical student near-peer-facilitators indicated that they believed their role as case designers and facilitators was beneficial. The goals of the near-peer facilitators were to stimulate discussion, highlight the ethical considerations presented in the cases, and explore different resolutions. Studies suggest that serving as facilitators in near-peer teaching methods has the additional benefit of maturing one’s own ethical reasoning skills and boosting confidence with communication skills [10, 17, 18].

End-of-year student narrative feedback identified areas for improvement related to the teaching modality and curricular content. Some students indicated that the large group setting was challenging for facilitating discussion, as the small group breakdowns occurred in the large classroom setting as opposed to smaller roundtable conference rooms. Additionally, some students suggested that they would prefer discussion led by physicians with systematic and “exact” answers to the ethical scenarios presented and discussion of more current politically charged ethical scenarios, such as abortion, cloning, and physician-assisted suicide.

Implementation of situational cases designed from real scenarios faced by medical students during their pre-clerkship years has the potential to not only foster comfort and confidence in students’ ability to recognize and address ethical dilemmas in a professional setting, but also inspire personal development of a stronger sense of moral identity and practical judgment through discussion among peers with viewpoints that will likely differ. More formal assessment of medical ethics knowledge and more in-depth analysis of surveys and feedback beyond this pilot study is needed.

Conclusions

This study demonstrates significant quantitative improvements in the abilities of first-year medical students to resolve ethical quandaries through adoption of a near-peer-facilitated case-based curriculum facilitated by second-year medical students. Additionally, near-peer-facilitated medical ethical educational sessions contributed to the professional identity development in first-year medical students by subjective measurements. This study provides additional objective evidence that near-peer facilitated ethics education is an effective strategy for teaching medical ethics to undergraduate medical students.

Appendix

Medical ethics case discussion outlines with detailed learning objectives and selected discussion questions for academic year 2017–2018

Session 1 (case 1): biospecimens and HeLa cells

Case description

Implications of the discovery of HeLa cells on modern scientific technology and medical discovery including topics of informed consent, health disparities, and ownership of biospecimens

Learning objectives

Discuss the historical impact of HeLa cells at a societal, legal, medical, and technological level

Outline the ethics of biospecimen and tissue ownership behind HeLa cells

Discuss the bioethical concepts of informed consent and fair subject selection

Evaluate and discuss the health disparities associated with HeLa cells and the ongoing obstacles faced by the Lacks’ family

Discussion questions

How should one appropriately go about getting informed consent? What information do you need to give to potential participants?

What groups of people may be disadvantaged regarding research, and what obstacles might they face?

How can we ensure that disadvantaged groups are not taken advantage of?

Who owns excised tissue samples?

If eggs, plasma, semen, etc. are able to be sold, why are other types of tissue not compensated for (transplants, biopsies)?

Session 1 (case 2): clinical research and genetic information

Case description

Current ethical implications of modern genetic information advancements including topics of clinical research ethics, the Common Rule, informed consent, risk-benefit ratio, and respect for subjects

Learning objectives

Describe current ethical considerations of ownership and disclosure of genetic information

Discuss the principles of research ethics emphasizing the common rule, informed consent, risk vs benefit ratio, and respect for enrolled subjects

Discuss the importance of discussing genetic counseling, limitations of genetic testing, and potential for future discrimination with patients

Evaluate and discuss the purpose and procedures for collecting informed consent in research and clinical trials

Discussion questions

Does genetic information belong to the patient from whom it was obtained or to the whole family? What is your reasoning?

What are some ways that patient information/identifying factors can be protected, especially in the new era of electronic medical records?

When is it, or is it ever, acceptable for a provider to disclose information about a patient? Why or why not?

Session 2 (case 3): advanced reproductive technologies and surrogacy

Case description

Historical timeline and background of advanced reproductive technologies (ART) with topics including the ethical, professional, and social considerations involving surrogacy and in vitro fertilization (IVF)

Learning objectives

Describe the current ethical guidelines and practice regulations of in vitro fertilization and surrogacy

Discuss the ethical and social considerations of advanced reproductive technologies and in vitro fertilization

Describe the role of the physician in counseling families and managing the healthcare of patients considering advanced reproductive technology

Evaluate and discuss some of the ethical considerations of surrogacy and multiple gestation pregnancies

Discussion questions

What populations may be targeted to serve as gestational carriers? How might surrogacy be regulated to avoid potential exploitation?

How might compensation influence informed consent?

What are the potential psychological effects on a child born from surrogacy? How else might these children be affected?

As physicians, are we obligated to aid otherwise infertile or same sex couples in achieving biological pregnancies via surrogacy?

Session 2 (case 4): genetic modification of human embryos

Case description

Current ethical considerations and recent regulation developments at the provider and societal level surrounding modern gene modification including topics of CRISPR/CAS9 and mitochondrial transfer therapy

Learning objectives

Discuss recent developments in the regulations and clinical uses regarding genetically modified offspring

Discuss the differences between gene modification for medical treatment versus enhancement

Describe the physician’s approach to discussing therapy with patients considering ethical, religious, and moral beliefs

Evaluate and discuss the ethical considerations of modern-day gene modification of human embryos

Discussion questions

What types of genetic conditions should be considered as targets for germline gene editing?

How could gene editing affect communities of people with certain conditions?

What is the difference between treatment and enhancement?

If an approved therapy is against a physician’s religious or moral beliefs, how should they approach discussing the therapy with patients that may potentially benefit?

Compliance with Ethical Standards

Ethical Approval/Informed Consent

This study was determined to be exempt by the Institutional Review Board at The Medical College of Georgia at Augusta University, as it was an assessment of an ongoing educational curriculum.

Conflict of Interest

The authors declare that they have no conflict of interest.