Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City.
South Med J. 2024 Mar;117(3):117-121. doi: 10.14423/SMJ.0000000000001660.
The objective of this study was to describe ethical and professional issues encountered and the ethical and professional values cited by medical students during their critical care clerkship, with a comparison of issues encountered before and during the coronavirus disease 2019 (COVID-19) pandemic.
In this single-center, retrospective mixed-methods study, two investigators at a midwestern US academic medical center performed qualitative content analysis on reflections written by fourth-year medical students about ethical and professional issues encountered during their critical care rotations between March 2016 and September 2021. We also analyzed the ethical/professional values mentioned in their reflections. Descriptive and inferential (χ) statistics were performed to examine differences in issues and values cited before and during the pandemic.
Respondents highlighted several key themes identified in prior studies, including decision making (64.1%), communication between clinicians and families (52.2%), and justice-related issues (32.1%), as well as interdisciplinary communication (25.7%) and issues related to the role of students in the intensive care unit (6.1%). Six novel subthemes were identified in this group, predominantly related to resource availability and end-of-life care. Of 343 reflections, 69% were written before the pandemic. Analysis of ethical and professional issues before and during COVID were notable for several significant differences, including increased discussion of inadequate tools/supplies/equipment (1.3% before vs 17.6% during, = 0.005) and/or access to care (3.9% before vs 17.6% during, = 0.03) and increased concerns about the tension between law and ethics (21.2% before vs 41.2% during, = 0.028). Primacy of patient welfare (49.8% before vs 47.2% during, = 0.659) and patient autonomy (51.1% before vs 38.9% during, = 0.036) were the most commonly cited ethical principles in both time frames, often discussed concurrently and in tension.
Although the COVID-19 pandemic was associated with increased reflection by medical students about resources in the intensive care unit, their perception of ethical issues arising in critical illness remained largely focused on enduring challenges in shared decision-making. These findings should be considered when developing ethics curricula for critical care rotations.
本研究旨在描述医学生在重症监护实习期间遇到的伦理和专业问题，并比较新冠疫情前后遇到的问题，同时描述医学生引用的伦理和专业价值观。
这是一项在美国中西部学术医疗中心进行的单中心回顾性混合方法研究。两位研究人员对 2016 年 3 月至 2021 年 9 月期间，第四年医学生在重症监护轮转期间所写的关于遇到的伦理和专业问题的反思进行了定性内容分析。我们还分析了他们反思中提到的伦理/专业价值观。使用描述性和推断性（χ）统计数据来检查疫情前后引用的问题和价值观的差异。
受访者强调了先前研究中确定的几个关键主题，包括决策制定（64.1%）、临床医生和家属之间的沟通（52.2%）以及与正义相关的问题（32.1%），以及跨学科沟通（25.7%）和与学生在重症监护病房中的角色相关的问题（6.1%）。这一组还确定了 6 个新的子主题，主要与资源可用性和临终关怀有关。在 343 份反思中，有 69%是在疫情前写的。对疫情前后伦理和专业问题的分析有几个显著差异，包括更多地讨论工具/用品/设备不足（1.3%在疫情前，17.6%在疫情中， = 0.005）和/或获得护理的机会（3.9%在疫情前，17.6%在疫情中， = 0.03），以及对法律和伦理之间的紧张关系的担忧增加（21.2%在疫情前，41.2%在疫情中， = 0.028）。在这两个时间框架内，患者福利至上（49.8%在疫情前，47.2%在疫情中， = 0.659）和患者自主权（51.1%在疫情前，38.9%在疫情中， = 0.036）是最常被引用的伦理原则，它们经常同时被讨论，并且存在紧张关系。
尽管新冠疫情导致医学生对重症监护室资源的反思增加，但他们对重症疾病中出现的伦理问题的看法仍然主要集中在共同决策方面的持久挑战上。在为重症监护轮转制定伦理课程时，应考虑这些发现。
