gms | German Medical Science

Ambitious expectations are placed on the teaching of medical ethics and the history of medicine in the medical curriculum. The aim of teaching ethics should be “to make cultural norms transparent, to give practice in critical approaches to them and to test their application in practice” [30]. The history of medicine on the other hand should encourage students to perceive and reflect “the changes of the historical context, of epistemological understanding and of moral convictions” [13]. A “differentiated integration of the history, theory and ethics of medicine in the sense of Medical Humanities” is judged to be very important in the curriculum for a positive “culture of medicine” [35]. Dropping humanities in medical school, in contrast, would have profound consequences [3].

But only with implementation of the Medical Licensure Act (AO) of 2002 did medical ethics and the history of medicine become components of compulsory studies in Germany, as a part of the cross-sectional area of the history, theory and ethics of medicine (GTE) which de facto replaced the previous courses in the history of medicine which the AO had recommended but not defined as relevant to examination. Since then, the subjects of the history of medicine and the ethics of medicine have been present in many medical schools in Germany as institutions [35].

Prompted by this process, the scientific interest in exploring the teaching of both subjects in Germany has intensified in recent years, seeking to link to the international community. The state of research in the two subjects is very different, especially with regard to empirical studies. While many studies with detailed methodology and results-oriented discussions already exist in the field of medical ethics, little empirical work has been carried out in the history of medicine. Since the history of medicine and medical ethics are often taught together, a simultaneous analysis of both fields is useful. As far as we are able to tell, only initial steps in research have been taken, which in addition focus on the evaluation of courses with ethical and historical content [42].

Against this background, we asked ourselves if the views and expectations of students towards the history of medicine and medical ethics at the beginning of their studies differ from each other and what influence the type of curriculum and subject-specific teaching has.

We used the initial hypotheses that

1.

views and expectations towards the history of medicine and medical ethics differ from one another

2.

they change in the course of study in the sense that subject-specific teaching has a positive impact whereas the so-called “hidden curriculum” has a negative impact.

1. Views

Numerous studies have already shown that the teaching of ethics is considered important by students ([23], [29], [33], [52], [54], [58], [60], [36], p. 106).

The course objectives which should be taught in an ethics course are equally hotly discussed as is the influence of medical studies on the students, its successes and the best time for teaching during the curriculum.

2. Aims

Wearn and colleagues in their New Zealand study refer to the United States where lesson content in medical ethics has changed. While teaching cognitive learning content, such as recognition and theoretical penetration of ethical dilemmas, stood in the foreground in the early 70s up until the 90s, modern developments aim to teach virtues and professional behaviour [61]. The current debates range from studies which conclude that professionalism cannot be taught (cf. [5]) to explicit claims calling for professional attitudes, abilities and skills to be adopted and taught as educational objectives [14] , [56].

Delaney back in 1988 had already found that among medical students at Oxford only about 20% in their 1^st and 2^nd year considered subject-specific teaching to have an impact on their ethical attitudes [10]. The majority stated that personal experiences and the opinions of consultants were crucial for influencing their ethical attitudes. Similarly, Lynoe and colleagues in Sweden were able to show that interest in ethics grows when students encounter good role models [33].

3. Impact of Medical Studies

Internationally there is a debate if medical studies in general have a “dehumanising” effect, encouraging a cynical view which endangers professional conduct and ethical reflectivity in students and physicians [5], [14], [61]; see also the overview in [7]. This assessment is corroborated by studies which have shown a lack of improvement or even deterioration of “moral judgement” and “ethical sensibility” in medical students during their studies [17], [18], [31], [32], [38], [47]; see also the overview in [6]. This discussion extends to the postgraduate area [59].

The realisation that this undesirable impact of the overall curriculum, the deliberate training objectives aside, has arisen unnoticed and inadvertently has led to rise of the terms “silent” [39] or “hidden curriculum” in the literature (see also the overviews in [6], [11]).

4. Successes

Overall, the effectiveness of teaching is often measured through the subjective attitude towards ethics [20], [29], [35], [52], [54], [57], [63].

Only rarely have the expectations of the students towards the teaching of medical ethics at the start of the first semester of medical school been evaluated as a reference, that is, prior to the actual start of undergraduate studies. Apart from our own previous research [43], [44], we were only able to identify one further study [36].

A comparison of the various studies on the effects of teaching ethics shows mixed results. In part this is certainly caused by the use of different research methods and different interpretations of the “success” construct. It has been demonstrated on the one hand that teaching ethics has a positive effect [16], [48], [50], [53]] and that it increases the willingness of a physician to act in morally challenging situations [8]. But on the other hand it turned out in the ethical assessment of case vignettes, for example, that teaching ethics had no impact [53]. A positive effect has been shown for working in small groups with regard to the construct of “moral judgement” [48], [49]. Leget developed a theory which states that students avoid classifying moral issues as such through specific argumentation strategies and thus the need to tackle ethical problem solving strategies [28]. It is no surprise that with such controversial results there is as yet no empirical evidence for the permanent success of teaching medical ethics which continues into medical practice, whether focussed on cognitive learning objectives or the teaching of professional behaviour (see [7], [11]).

5. Timing

There are demands for teaching medical ethics at various stages of the curriculum. The proposals range from starting as early as possible [2] or continuous training ([54], [34] and [55], p. 26) to instruction during the clinical part of studies [22]. Older studies even call for it not to be taught until the start of medical practice [1], [9].

There are only isolated empirical studies regarding the history of medicine, for example by Sheard from Liverpool. In Liverpool, the history of medicine was offered from 1996 to 2003 and was uniformly evaluated positively by the students [51]. A similar result has also been reported from Michigan but without empirical basis [21].

Accordingly, the importance of teaching the history of medicine or humanities in medical studies is noted in numerous publications [3], [21], [27], [35], [37] with a focus on personal experience, theoretical considerations and educational ideals.

On the other hand there are repeated complaints that students only rarely have a positive stance on the history of medicine content but without supporting this claim with empirical data [19], [37]. Helm concludes that it is one of the main tasks of the history of medicine education to explain to students why knowledge of the history of medicine is important for them [19]. This demand is linked to the more or less prominent debate about the relevance of the subject for medical studies which has been ongoing since the discipline was institutionalised at the medical faculties – debates which the history of medicine has tried to address using contemporary legitimisation strategies [4], [15], [19], [24], [25], [26], [41], [45], [62].

We developed a questionnaire with two item groups. In order to be able to link pre- and post-questionnaires of each participant, a personal code was also requested.

The first item group included personal data. We asked for the age, gender and academic semester.

The second item group included statements to test our hypotheses which were rated on a Likert scale ranging from -2 (strongly disagree) to +2 (strongly agree) (see Figure 1 [Fig. 1]).

When the study was set up, several tools for evaluating expectations towards medical ethics already existed in the literature [20], [52], [54] but none which allowed for a simultaneous analysis of medical ethics and the history of medicine nor for the history of medicine alone. We therefore designed new items in a way which would allow us to collect changes during the degree course and to compare the expectations towards medical ethics and the history of medicine (see Figure 1 [Fig. 1]). Since then, similar items have been published in other studies too, for example in the cover sheet questions in the LoF-ME developed by Möller in her dissertation [36] and the questions used by Sheard in Liverpool for the evaluation of the teaching of the history of medicine [51].

As the Ruhr-University Bochum (RUB) offers a model degree course in medicine in addition to the traditional curriculum, we asked students of both curricula separately and used the different curricula to answer our research questions.

The decision on whether a student is assigned to the model course or the traditional curriculum is usually decided through an application procedure in which 42 places are allocated to the model course once students have been offered a place in Bochum. If there are more applicants than available places, students are assigned through a lottery.

In the traditional degree course in medicine at the RUB (approx. 260 students), GTE is taught as a one-hour lecture during the 5^th and 6^th semester. At the end of the course attainment is controlled using a MC (multiple choice) examination.

In the model course (max. 42 students), teaching stretches from the 1^st to the 10^th semester. The model curriculum contains two compulsory modules (1^st and 8^th semester, each with one hour per week for one semester) and one elective part (2^nd to 10^th semester, 3 short seminars, each lasting 6 hours). Seminars constitute the general format of instruction in all cases. In the two compulsory modules, attainment is checked using a written MEQ (Modified Essay Questions), the elective does not conclude with an examination.

At the start of the winter semester 2005/2006, the questionnaire was distributed to all students of both the model and traditional curriculum in the first and the fifth semester (pre-questionnaires). The second student survey took place at the end of the winter semester 2005/2006 or in the case of the cohort of the fifth semester of the traditional curriculum at the end of the summer semester 2006 (post-questionnaires). The students in this cohort were surveyed later than the other groups because their subject-specific teaching stretched over two semesters.

For all groups, key lectures where all students had to be present were used to distribute the questionnaires. The purpose of the survey was explained to the students and the questionnaires were handed out. The questionnaires were collected immediately after the lecture again.

In total 533 students were surveyed. The response rate of the questionnaires in each subgroup ranged from 58% to 95%. For a total of 331 (62%) of all students, both pre- and post-questionnaires were available. At the start of the medical school, we found no significant differences between the traditional curriculum and the model degree course regarding the personal data of the students and the evaluation of all items.

When comparing the assessment of the ethical items with the historical items, we obtained results which were opposed to each other. At the beginning of medical studies the importance of medical ethics for the individual and the physician is already rated significantly higher than in the case of the history of medicine. In contrast, the history of medicine is assessed as being significantly more teachable, learnable and testable (see Figure 2 [Fig. 2]). Thus our hypothesis was confirmed which stated that medical ethics and the history of medicine were viewed differently by the students.

The hypothesis that instruction has a positive effect on the assessment of medical ethics and the history of medicine is, both in the traditional curriculum group and the model degree course, in accordance with our results.

In the model degree course the assessment of the testability of medical ethics and the importance of the history of medicine for the physician improved significantly in the course of the first and the 5^th semester of study. No significant differences were detected for the other items in both semesters (see Table 1 [Tab. 1] and 2 [Tab. 2]).

The testability of medical ethics and all items relating to the history of medicine in the traditional degree course were assessed more positively after the end of the 6^th compared with the start of the 5^th semester (see Table 2 [Tab. 2]).

When comparing the survey results for the model degree course at the end of the 5^th semester with the survey results of the traditional curriculum after the end of the 6^th semester (the same stage of training), the assessment in the model course of all items relating to medical ethics is significantly more positive (p<0.05, compare the basic values in Table 2 [Tab. 2]). However, no significant differences could be found regarding the history of medicine.

Our hypothesis that a lack of teaching has a negative impact on the assessment of medical ethics and the history of medicine is, again, in line with our results. It is particularly revealing to compare the values from before and after the first semester of the traditional degree course. The significant deterioration in the assessment of the teaching of medical ethics and its significance to the individual and the physician is notable. Moreover, there is a significant deterioration in the assessment of the teachability and testability of the history of medicine (see Table 1 [Tab. 1]).

When comparing the model course and the traditional curriculum at the end of the first semester, the significantly higher assessment of the importance of the history of medicine to the physician and the more positive assessment of the testability of medical ethics by the students of the model course is notable (for both items p<0.05, see values in Table 1 [Tab. 1]).

Regarding medical ethics, the results for the first two items of our questionnaire in particular have been confirmed many times in the literature but rarely explicitly at the beginning of medical school ([36], p. 89, possibly also [12], [54], [58]).

Education in medical ethics for the individual [2], [23], [29], [33], [52], [54], [58], [60] and the physician is regarded as important [36], [46], [54], [57]. However, the assessment of teachability and testability were rarely asked. In contrast to Roberts [40] but in accordance with Möller [36], pp. 102-108, our study found the assessment of the teachability of medical ethics not to be particularly positive. Similarly, the assessment of its testability is poor. Both require an explanation as it contradicts the high appreciation of the subject. It is therefore necessary to subject the construct of “ethics” amongst first-year students to a more extensive analysis.

Exactly the opposite is the case for the students’ assessment of the teachability and testability of the history of medicine. It seems plausible to hypothesise that the history of medicine is assessed against the backdrop of experiences with the subject of history at school, with the students already being aware that history is both testable and teachable. It is also possible that students have also learned in school that history is hardly relevant for their present actions and therefore assess the importance of the history of medicine for themselves and the physician as being rather low. This hypothesis is consistent with recent reports by educators [19], [21], [51] but also with the historical knowledge that the history of medicine as a humanities subject in medical schools, in an environment increasingly seeing itself as a science, has been under pressure to justify its presence since its establishment [4], [15], [19], [24], [25], [26], [37], [41], [45], [62].

These are not encouraging conditions to achieve the ambitious learning targets aimed for by the teaching of the history of medicine. Our results on the effects of professional training on the students show that it is possible nevertheless.

Semesters where the history of medicine is taught improve the views on the subject. This effect is visible both in the first semester of the model course where the assessment of the importance for the physician improved significantly and after the 6th semester in the traditional curriculum, where all items were rated significantly more positive.

In the case of medical ethics, in all semesters where medical ethics was taught the assessment of the testability of the subject improved. Because teaching cumulates in an exam in these cases, this could not only point towards better assessment of the testability of medical ethics per se, but simply towards the relationship between teaching and examination. In other words, whether the exam was fair and whether or not it resulted in acceptable exam results. This interpretation is corroborated by the answers regarding the teachability of ethics, as these show no significant differences.

The assessment of its significance for the physician and the individual did not change through the teaching of medical ethics. But when interpreting these results the high initial assessment level should be borne in mind. The very positive initial values confirm the results of other studies which we have already mentioned.

The occurrence of a deterioration of views if the subject is not taught is shown by the assessments regarding medical ethics in the first semester of the traditional curriculum. There was a significant deterioration over the course of the semester regarding the importance of medical ethics for the individual and for the physician (see Table 1 [Tab. 1]). Against the background of our research results the effect of the hidden curriculum can be suspected to be the cause.

This assumption can be supported by comparing the 1^st and the 5^th semester of the traditional degree course which shows a significantly lower assessment of the significance for the individual and the physician and the teachability at the beginning of the 5^th semester. The positive effect of the teaching of ethics in the 5^th semester of the traditional curriculum could then be seen as stemming further deterioration. In this respect, our results are consistent with the studies mentioned above which found a positive effect of teaching ethics at other levels or have demonstrated the interest of the students in this topic. As our data was compared transversely rather than longitudinally, this only deserves to be treated as a tentative, exploratory assessment which needs to be verified by a longitudinal study.

The continuing positive view of medical ethics in the model course where medical ethics is taught from the start can be interpreted in line with these considerations. This is limited by us only being able of analysing periods in which medical ethics was taught and therefore it does not distinguish between the influence of specific teaching and the influence of the hidden curriculum.

The assessment of the history of medicine in degree course sections without teaching also deteriorated. However, in contrast to medical ethics, both the items teachability and testability are affected.

In spite of this difference, there are striking similarities between both subjects. Only those items are affected by deterioration which were judged particularly well by the students initially. Items which had been rated negatively showed no significant differences on the other hand. Perhaps this is an indication that the hidden curriculum does not lead to a strong, explicit rejection of both subjects (Likert scale: values -1 or -2) but relegates them into irrelevance (Likert scale: 0). This would have to be analysed in future studies.

The stance on medical ethics and the history of medicine thus generally improve in semesters where they are taught according to our results. In this respect the timing of teaching within the curriculum does not appear to be critical at first glance. But at least with regard to medical ethics, our results support the hypothesis that continuous education, which begins in the first semester, has a stronger effect. As it turns out, medical ethics at the end of the 5^th semester of the model course, where medical ethics is taught continuously from the 1st semester onwards, all the items were assessed more positively by the end of the 6^th semester compared to the traditional curriculum, where the teaching begins at the second stage of studies. It must, however, be considered that not only the timing of teaching and the time taught in Bochum differs between the model course and the traditional curriculum but also the instruction format (seminars in the model course and lectures in the traditional curriculum) and possibly also the hidden curriculum.

For the first time, we were able to demonstrate that medical students at the beginning of their studies assess the history of medicine and medical ethics fundamentally different through an empirical study. In the case of medical ethics, the teachability and testability is judged as being low, in the case of the history of medicine, high. The importance of medical ethics to the individual and the physician on the other hand is rated as high and in the case of the history of medicine as low. This must be taken into account in the planning and implementation of teaching.

Our results also support, in line with the literature, the hypothesis that a lack of teaching has a negative effect by allowing the hidden curriculum to impact views in an unbridled fashion.

It should therefore be demanded in general that the teaching of GTE begins as early as possible, preferably already in the first semester. It also appears to make sense to offer it continuously over a long period of time.

Both medical faculties in Germany and the institutes for medical ethics and the history of medicine are therefore called upon to break with the traditional structures of education in GTE. A glance into the Licensure Act shows that this is possible in principle, as it stipulates in §1 (3) that the cross-sectional topic of GTE has to be examined between the first and second section of the Medical Examination but does not indicate specifically the timing of instructions.

Stefan Schulz and Barbara Woestmann are joint lead authors.

We would like to thank Dr Heinz Endres for providing advice regarding the statistical analysis of the data.

The authors declare that they have no competing interests.