# introduction

At the Université de Montréal, like most North American medical schools, the four-year curriculum has been developed to include the teaching of ethics and professionalism. Over the first two years, under the supervision of a clinician, small groups of 10 to 12 students examined and discussed classic cases of ethics, bioethics and professionalism. This is the introduction to ethics and moral reasoning and the beginning of the transmission of a professional idealism. With this background, students reach the clerkships and begin their clinical training. They now must work in the hospital setting, with daily interaction with patients, residents and staff, and this transition is not always easy (1). Some students are anxious about their new role as an apprentice doctor, as this brings with it the stress of learning the fundamentals of clinical science while performing procedures on patients. In this context, students are not yet knowledgeable about the moral dilemmas that they will encounter as a medical student and later as a practicing physician.

As medical educators, it is our responsibility to sensitize our students to the challenges of ethics and professionalism issues they will meet during the clerkships. Many medical educators have mentioned the need to listen to medical students to understand the ethical questions or dilemmas that they encounter in the hospital and clinic (2-6). These ethical issues are not theorical abstractions or a simple choice between true or false, right or wrong — they are much more complex (3). Knowing about the difficulties of teaching ethics and professional behaviour in the context of a very busy surgery department, the authors (GB and RW) decided to implement, during the surgery rotation, a seminar on ethics and professionalism with a view to helping students recognize and better reflect on these issues. This paper analyzes the results of 16 years of written narratives provided by third-year medical students during their clerkship in surgery.
# METHOD

## Teaching ethics and professionalism

During the clerkship in surgery at the Université de Montréal, medical students do two three-week rotations, one in general surgery and a second in a subspecialty such as vascular, urology and thoracic surgery. Students spend their time caring for surgical patients on the ward, in the clinic, and in the operating room. They are exposed to complex cases, participate in the investigation of patients; and they are introduced to the operating room environment and participate in some surgeries. This is their first exposure to the speciality of surgery. While they will have learned about ethical principles and their medical code of ethics during the pre-clerkship, these students also need to learn to identify and analyze the ethical issues that occur every day in surgical practice (2,3).

At the very beginning of their surgery rotation, a group of 8 to 12 students would meet with the facilitator (a clinician-educator) responsible for leading the ethics and professionalism seminar. After a brief review of the fundamentals of ethics, the students were provided with a definition and explanation of what constitutes an ethical dilemma, what is a professionalism issue, and with specific examples related to surgery. Ethical dilemmas were defined as situations in which there is a conflict between two or more moral principles, making it challenging to decide on the right course of action. These situations arise in various aspects of life, including personal decisions, professional conduct, and societal issues (7). Professionalism is at the core of medical practice and forms the basis of medicine’s contract with patients and society. The values of the profession include competence but also compassion, altruism, trustworthiness, protection of confidentiality and privacy as well as responsibility and accountability, to name a few fundamental values (8).

In this seminar, professionalism was incorporated because of its close interdependence with ethics and because professionalism often includes adherence to ethical principles and the use of moral reasoning (9-13). Even if some people find it difficult to articulate or distinguish ethics and professionalism, in our experience students had no difficulty understanding that professionalism included adherence to ethical principles, ethical virtues, and moral reasoning. Health care ethics often invokes values and principles, whereas professionalism tends to encompass but also move beyond principles by invoking moral resources such as attitudes, commitments and motivations traditionally associated with virtue ethics. While the contrasting emphases of principles and virtues are real, they can be understood as complementary aspects of the same ethics.

An ethics or professionalism critical incident was recognized by students as a clinical experience that involved patients or families, hospital personnel, residents, medical students or any educator, and which raised an ethical or professionalism issue with which they personally had difficulty. A critical incident could also be a situation or a difficult issue that they had observed a clinician dealing with in an exemplary fashion. Critical incidents reports are widely used in medical education to promote reflective learning and are based on an event chosen by the student that influences their professional development (14-17). Professional and ethical issues in surgical rotations are particularly relevant for students because they highlight the reality of and challenges that emerge in everyday practice (18-20).

“Narrative medicine” is the term introduced by Dr Rita Charon to describe the application of story to medical education and practice (21). The students in the ethics and professionalism seminar were asked to share a brief story describing a critical incident they experienced during their surgery clerkship. Writing this story as a narrative is significant because it encourages the writer to pursue the meaning of the experience they are describing and reflect on their thoughts or behaviours. Moreover, when others read and respond to the narrative, the discussion process promotes further reflection on the part of the writer. Writing narratives may also increase ethical sensitivity, as the process of writing can help the writer to recognize ethically important moments and so increase their ethical mindfulness. Further, the act of writing a medical narrative can appeal to both rational and emotional faculties, forcing the writer to question why they felt as they did and what the patient might have felt (22).

The students had to identify a critical incident, describe it in a one-page written narrative and make a judgement on whether the situation they were reporting was morally acceptable (positive) or questionable (negative). They then had to give their opinion on how the dilemma should be resolved. Students were asked to keep the narrative anonymous, and they were aware that their narratives would be discussed at the end of the rotation, during the seminar. At the seminar, the facilitator’s role was essentially to stimulate the discussion and complete the information (e.g., raise questions or concerns) about ethics and professionalism. At the end of the seminar, students were asked to complete a written evaluation and grade the quality of the class and their level of learning.

The results collected show that the seminar enabled third-year medical students to better identify an ethical dilemma or a professionalism issue. Further, their comments showed that most were happy to participate in the seminar and grateful for the opportunity to talk freely about some problematic issues that they encountered during their rotation. Many stated that in other rotations they had never had such a frank discussion about ethics in medicine and professional behaviour. They were also asked to identify if a surgeon, a resident, or another person had been a role model: of 125 evaluations, more surgeons (n=53) than residents (n=49) were seen as being good role models, although 21 students felt that residents and staff were equally good role models. Only 2 students reported that they found no good role model at all in their clinical rotation.

## Analysis of the student narratives

Between January 2004 and 2020, 1145 narratives written by third-year medical students at the Université de Montréal (Montreal, Canada) were collected following each ethics and professionalism seminar. These narratives were read and analyzed by one of the authors (GB), to identify and better understand the ethical or professional issues encountered by students during their clerkships. These issues were then organized into a taxonomy with 5 sub-groups of ethical dilemmas and 9 sub-groups of professionalism issues (see Table 1, below).

The students’ narratives were also analyzed with regards to their judgment of the critical incident and its management by the surgeon and their team, i.e., a positive or a negative opinion. A positive narrative reported a critical situation judged to be in conformity with key ethical principles or the professional code of ethics. For example, a critical incident was perceived positively by students because it demonstrated respect, good communication and compassion for the patients. It was found excellent if the behaviour of the health care provider was in alignment with evidence-based science and carried out with humanism. By contrast, a critical incident was judged as negative when ethics principles were forgotten or simply not used in the resolution of an ethical dilemma. In the case of unprofessionalism, a major lapse was identified in the attitude or the behaviour of a member of the health care team (see Table 1, below, for the number of positive and negative narratives for each subgroup).

The students were not consulted to confirm the relevance of the different categories of the taxonomy, nor were other steps taken to ensure trustworthiness of the coding themes. Nonetheless, this work was presented on two occasions to students and staff of the Department of Surgery at Université de Montréal, and on one occasion at the Department of Surgery at the Université Laval. There were no negative comments on the taxonomy.

## Ethical considerations

After the completion of the seminar, students were given the choice to leave a copy of their narrative with the facilitator or have it destroyed. It was clearly explained to the students that their narrative would be kept anonymous and remain confidential; only the facilitator would have access to the narratives, which could be used for research purposes in the future. The data presented here are fully anonymized and only include those narratives which students had initially accepted to be potentially included in research. Retrospective ethics approval for the use of these student narratives for research purposes was obtained from the Université de Montréal Health Sciences Research Ethics Board (CERSES).
# Results

The findings reported here are descriptive and retrospective, with a view to capturing the ethical issues that students encountered during a rotation in surgery. We tried to identify, when possible, the moral reasoning of the students to justify their opinion. Most of the time students referred to bioethics principles in their narratives, but rarely to ethical theory; in the case of professionalism issues, they referred to the code of ethics. Further, in some narratives or in their discussion the student’s emotional reaction to a critical incident was evident, so we have identified these where pertinent.

A total of 1145 written narratives, written during the period of 2004-2020 by third-year medical students participating in an obligatory ethics and professionalism seminar, were retained for this study. Each narrative was classified as a critical incident related to a clinical ethical dilemma (n=396) or a professionalism issue (n=749), and then sub-categorized (Table 1). The narratives included a discussion or opinion on the critical incident reported, where they explained why they agreed or not with what they had observed, with a reference to ethical principles or the code of ethics. (See Annex 1 for a lengthier analysis of the ethical dilemmas and professionalism issues, with examples from students’ narratives)

<table><caption>Table 1 — Category and sub-category of reported narratives</caption><tr><td>Ethical dilemma issues (n=396)+ve-veProfessional behaviour issues
            (n=749)+ve-veEnd-of-life decisionsn=17212349Communication with patients and
            familyn=1426676Treatment decisionsn=1116645Communication of bad newsn=1688979Justice and
            health care resource dilemmasn=48147Obtaining consentn=1104334+33Student-specific
            educational issuesn=41140Confidentialityn=561937Student relations with
            residentsn=241032Truthful disclosuren=381028Dealing with medical
            errorsn=33429Professional duties, conduct and attitude with patients and
            staffn=1434499Professional responsibility and commitmentn=341123Relationships with
            medical colleaguesn=25322</td></tr></table>

The most prevalent issues experienced by students were related to communication (n=458), such as communication with patients (n=142), communication of bad news (n=168), consent (n=110) and disclosure (n=38). The second category of importance had to do with issues of professional behaviour (n=291), such as duties and conduct (n=143), confidentiality (n=56), dealing with medical errors (n=33), responsibility (n=34), relationships with colleagues (n=25). The third category of issues had to do with decision making (n=283), end-of-life decision-making (n=172) and decisions about surgical interventions (n=111). The fourth category of importance was education (n=65), while the last concerned the health care system (n=48).

The critical incidents described by students were considered as positive in 435 (38.8%) and negative in 685 (61.2%) of the narratives. Communication was considered far from ideal in 217 of 458 narratives (47.7%). The comments on professional behaviour (n=99), confidentiality (n=37), errors (n=29), responsibility (n=23), and relation with colleagues (n=22) were negative in 210 of 291 narratives (72%). With respect to decision making, in 283 narratives, 189 were believed to be adequate (66.7%). For education, 54 out of 65 narratives were negative (83%). For 48 narratives on health care and resource dilemmas, almost all comments were negative (95%).

In their narratives, students referred to the four well known bioethics principles, namely autonomy, beneficence, non-maleficence, and justice, and used these for the discussion and explanation of ethical dilemmas. For professional behaviour, most students referred to the code of ethics or the law, although a small number of students also referred to the principles of autonomy and beneficence for professionalism.
# Discussion

To lay the conceptual and empirical groundwork for this study, a review of the literature on ethical issues and professionalism encountered by medical students was conducted (20-31). Numerous studies have explored pre-clinical and clinical medical students’ experiences of ethical and professionalism dilemmas using different method such as surveys, focus group or written essays; and over the years, the use of narrative has become a very popular method to explore student experiences.

The information generated by the study of students’ narratives, combined with those reported in the surgical literature, have enabled scholars to develop various lists of ethical issues experienced by medical students. Fard et al., for example, provides an extensive list of ethical issues, including professionalism, conflicts of interest, resource allocation and justice, patient-relationships, autonomy, informed consent, determining capacity and substitute decision-making, confidentiality, truth telling, doctor and medical team relationships, medical error, ethics in medical education and terminal illness issues (23). Kadijan et al. present a more limited list of issues, such as decisions regarding treatment, communication, professional duties, justice, student specific decision, and quality of care (24). For our analysis, we combined these two taxonomies to include as wide a range possible of ethical and professional challenges that students encounter in their medical training.

Our analysis of 1145 student narratives collected over a 16-year period showed that third-year medical students can identify and capture the nature of ethical dilemmas arising in the care of patients. They observed very well the quality of interactions and relationships in the clinical and educational settings, and they develop advanced reflexive skills, while maintaining their idealism. The students were very critical about the interactions between the surgical team and the patients and family. They referred to patient best interest and they observed how well (or not) patient needs were met in the hospital environment, the quality of the communication between patients and staff, and the positive or negative attitude of the different actors of the health care team. When it came to patient care, students expected to see ideal ethical and professional conduct from every member of the health care team; and they expected medical educators, residents, and health care professionals to be role models.

Students were very critical of the way that their education was conducted. Across studies, the most common dilemma is about students’ difficult experiences with learning and patient care, but also frequently reported are issues about respect and communication. Student reactions and responses are often influenced by fear of jeopardising their evaluation or their career plan; and a result is moral distress and negative feelings (30). In our study, students were extremely sensitive to the atmosphere in which they did their clerkships, appreciating a milieux that was open, friendly, empathetic, cooperative, respectful, and humanist. And communication was of utmost importance for them. Students were most troubled when there was a problem of poor relationships between colleagues. They were also very upset when there was public discord within the team. It is in the narratives dealing with education-related issues that students appeared to be most uncomfortable or upset. Some narratives expressed deception or anxiety due to feeling inadequate to accomplish an assigned task. The student narratives provided an authentic description of a medical learning environment, and we should listen to their messages.

It has been observed that third-year medical students are prone to forget about the importance of empathy and compassion learned theoretically during preclinical training. The necessity to stay current with the latest developments in medical knowledge, combined with the burden of clinical workloads and institutional requirements for efficiency can threaten essential ethical and professional values that were considered fundamental in the preclinical years. This was not the case with our student narratives. Over the years, they showed a very good sense of observation and sensitivity for ethically problematic situations. On no occasion did we witness cynicism from the students, nor was their judgment ever ineffectual; in fact, their judgment was generally very good even when discussing difficult situations.

Contrary to some reports in the literature, our students did not remain silent about the hidden curriculum (32,33). They used the seminar to talk freely about the good and less good ethical issues that they have encountered, probably because the seminar was a safe space to express their feeling and opinions. In the process of socialization in medical school, students learn rapidly to hide their emotions, and all their attention is given to the facts of a case, to objective data; there is less interest for the subjective acknowledgement of emotions. When students reported a critical incident for which they agreed, they had positive emotions or did not manifest any emotion in their report. We did not find many negative emotions but noted the sensitivity of students when the critical incidents they had observed were in contradiction with their values, ethical principles, or the code of ethics (11).

Medical students on clinical rotations are incredible observers of their educators’ behaviours; and they have the potential and capacity to register our actions, smiles, and insinuations. As clinicians, we must realize that our practice is public, and it is closely observed by many persons around us, but most of all by our students. In their narratives, students were very critical when professional behaviour in the operating room was inadequate or when a medical decision was influenced by a prejudice. This analysis of the students’ narratives shows that medical students have a good sense of observation of both the training environment and the professionalism (or lack) of their clinical educators.

Throughout the years we conducted the seminar on ethics and professionalism, the students demonstrated energy and enthusiasm and a very good cooperation, even if there was no direct evaluation of their performance at the seminar (it was not a graded activity). Our analysis points to the important role of the hidden curriculum in shaping professional identity. It also showed that third-year medical students may be more aware of ethics and professionalism issues than one might first assume (32-35).

In 2005, Branch described the effectiveness and impact of reflection when using critical incident reports, pointing to the importance of a reaction to and validating discussion environment, and the benefit of transformative learning (15). Reflective writing of short narratives has been shown to be an effective means of teaching professionalism when combined with feedback. Written reflection is associated with a more positive learning experience because students revisit and assess their experience, and this can help them progress in their self-reflection and eventually develop and implement high-quality practice (17). Reflection is a technique that enables learners to analyze their experience and capture the wisdom that lies within, and to then develop new knowledge and attitudes. Reflection is also associated with positive learning experiences and may help students to develop as learners and better recognize their own learning needs (16). Reflection and feedback for the teaching of ethics and professionalism involves the intentional examination of a learning experience, including feeling, meaning, and ethical implications. Discussing critical incidents related to ethics or professionalism experienced by students may stimulate self-reflection and lead to mindfulness and help in building students’ professional identity (32-37).

Combining reflective narratives with the good role models they find during their rotation in surgery can help medical students to answer questions like: What kind of doctor will I be? What are my values? What are my convictions to become a good doctor? According to White, one of the most formative influences in medical education is the recognition and reflection of students on critical incidents encountered during a rotation (17).

By using the narrative approach, we wished to stimulate students’ ethical sensitivity and help them develop their reflection and judgment. Essentially, the idea was to prepare them for the subjective aspects of the practice of medicine. We wanted them to learn to identify or recognise ethical dilemmas in surgery, to analyse them and resolve them were possible, and to discover their own personal ethic, along with its rationales and motives (7). Can one be a scientific and competent professional while only giving minimal consideration for the art of medicine? Is it important to become a humanistic doctor with high standard of ethics? In answering these and other questions, medical students construct their professional identity.

Learning reasoning about ethics and professionalism and observing role models while training enables medical students to progress gradually to find their own professional identity. We hope they will maintain their well-developed identity acquired during their clinical rotations and medical training, and throughout their professional career. In our case, we thought a seminar that favoured observation of practical issues in ethics or professionalism and stimulated reflection on a critical incident followed by a small group discussion would be an appropriate educational modality with which to teach ethics. Specifically, it would help students to reflect upon and learn about their clinical experience, which they lived during a 6-week rotation in surgery. This formal activity can be in addition to the habitual teaching of ethics during their exposure to surgery.
# Limitations

One of this study’s limitations is that the data were collected in a single institution, in Quebec (Canada), and so may not be generalizable to other institutions. The seminar experience reported here was also conducted in another hospital, but the narratives were never collected and analyzed. The study also concerns a limited number of students from a group of approximately 200 students assigned every year in a clinical rotation of approximately 3000 students. The study involved 25 surgeons, the majority from General Surgery, and the others from vascular, thoracic and urology. The evaluation and interpretation of all the narratives was done by a single person (GB). Nonetheless, the lessons learned from the students’ narratives provide insight into how medical students are trained and this is pertinent for all medical schools to consider. Specifically, surgeons and medical educators should be aware that they are constantly observed by their students, who will judge their behaviours — clinical educators can be positive or negative role models, because what is learned by students is both content and behaviour.
# Conclusion

Medical education is not simply the acquisition of knowledge and skills — above all, it is the acquisition of a professional identity and the identification of values that will guide professional conduct. Medical students desire to become proficient and caring physicians. The students who participated in our seminar shared their belief in the professional virtues of altruism, honesty, integrity, excellence, respect, and responsibility and wished to learn from good role models encountered during clinical rotations. Negative behaviours observed by students are teachable events because they show students what is not appropriate and sometimes this is more instructive. It is an occasion for students to develop mindfulness and reflect on what went wrong and the negative effect on the persons involved. The findings of our study suggest that students’ reflective narratives are a rich source of information about the informal of hidden curriculum. Experience with both positive and negative behaviours were distributed evenly and shaped the students’ experience of the professional values in the daily practice of surgery. Good communication and professionalism of surgeons appeared for the students as fundamental values.

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