Katherine France

Ethics and professionalism, long recognized as pillars of student education in healthcare professions, have increasingly become topics in discussions of curricula and educational culture. This shift mirrors general recognition of the hidden curriculum (tacit assumptions not every student knows) in professional education. In healthcare fields, setting expectations for ethical behavior allows students to use their academic and personal strengths to learn how to build relationships with their patients while they learn the knowledge and techniques that receive more direct attention.

During the Penn Dental Medicine curriculum overhaul in 2015, the school added ethics to the didactic curriculum in the form of both lectures and seminars during each of the first three years. By all measures (faculty experience, student feedback, board exam results in relevant topics, and others), the addition of this subject matter has made a positive impact. Students can then apply that knowledge in clinical encounters as they practically evaluate ethics dilemmas and practice decision making. 

In the clinics I teach in, I spend a few minutes before students begin each patient’s care raising questions around topics such as capacity, informed refusal, patient choice in determining treatment options, or related ethical considerations as applicable. These are examples that are relevant almost every day, both in my teaching and in my own practice, and therefore are opportunities to improve student learning, care, and patient outcomes.

For example, questions about surrogate decision-making are intimately related to care. In these situations, I talk with the student about how to engage a patient while also addressing the desires of the surrogate decision maker, apply substituted judgment together with a caregiver if the patient cannot express symptoms or desires, or even consider when to decrease attention on a family member’s desires and instead attend to the primary patient’s stated concerns. This becomes particularly poignant, for example, when an elderly patient who retains decision making capacity may disagree with a child or other younger caregiver. Holding a discussion ahead of time allows students to intentionally consider ethical issues around who makes decisions about treatment, what are the different possibilities, and the impact of various options. 

I also encourage students to consider the patient’s own desires and remind students about their responsibility to the principles of autonomy and justice. Throughout their careers, students will frequently treat minors, patients with cognitive deficits or developmental differences, and patients who for a variety of reasons may have limited or no independent capacity to decide the course of their dental care. In discussing our approach to these patients, I encourage students to consider our ability to do good in cases where patients may lack full ability to express themselves, as well as limits to that principle. This occurs regardless of specialty given its breadth. 

Similarly, questions of informed consent and refusal are central tenets of bioethics, both in theory and practice. Despite this, students may not fully think through them, even when considering some of our most serious procedures, whether according to risk, irreversibility, or investment. Indeed, academic dentistry needs to understand the variety of reasons why patients might refuse our treatments, or why they might want to shape the treatment plan differently based on their own priorities. I help students consider how education may help patients understand the value of the treatment being proposed, especially in the common dental case of asymptomatic disease that may progress to worse outcomes such as dental caries and periodontitis. I also help students talk through how to address patients’ rational or irrational reasons for refusing treatment. For example, patients who have learned to distrust healthcare may be suspicious of applications of fluoride, despite the clear scientific benefits. Students must learn not to dismiss these anxieties. Additionally, I encourage students to consider their own biases when proposing treatment, asking them to be aware of ageism (not providing as many options in a patient who may not be able to maintain the results), classism (suggesting different treatments based on presumed ability to pay), and other factors. Alongside these considerations, I try to have the student consider their own background, experiences, and preferences and reflect on how to treat patients who are different from them. Identifying these identities and how they apply will allow students to better explain options to their patients and engage with basic and advanced ethical principles instead of knee-jerk reactions. 

I hope to get students to use an ethics framework to consider if they should always treat conditions as they arise. Students regularly encounter asymptomatic variations of normal or mildly uncomfortable conditions such as aphthous ulcers (canker sores). Instead of automatically assuming that more treatment is better, I ask students to consider what the true balance of good and harm would be: what might be the expected benefit of treatment and are there any risks of progression or other untoward events if not treated? In these conversations, students come to understand the impacts of action as well as wise monitoring, and can engage questions of critical thinking, not just applying biomedical principles.

Students are capable, if hesitant, to take on both straightforward and murky applications of these and other ethical dilemmas. While they might prefer to stand back and be told an answer, I find that if I push them to think, they are able to and interested in choosing and supporting a firmer decision. To help students, I create a growth-minded learning environment. I begin by building community and treating my students as valuable and capable moral actors. I spend time with them outside of patient appointments to build personal relationships so that in stressful moments, I can challenge them with questions: how should we deal with our discomfort if a patient refuses the fluoride we recommend? How do we think about the approach of allowing a caregiver to make the decisions for a patient who cannot communicate independently? Takeaways from these conversations can allow students to manage charged moments and to build a trusting connection. 

Because students face these debates in practice daily, ethical dilemmas should have equal standing with questions of differential diagnosis and determination of etiology. All clinical faculty members should name and discuss the ethical considerations always present in discussion of treatment options. Just as students have opportunities to grow in this field, clinical faculty can develop their ability to facilitate these conversations through the excellent courses offered through the department of medical ethics and health policy at the Perelman School of Medicine and the many applicable sessions hosted by the Center for Excellence in Teaching, Learning and Innovation (CETLI). In fact, CETLI has recently established a semesterly series on teaching ethics in professional schools that has provided me with excellent practical tools to apply in both clinical and didactic teaching. Just as we do in patient care, our teaching should be ever evolving and improving, and ethics is a low hanging fruit where new skills materially result in good for our students and their future patients.

Katherine France is an assistant professor of oral medicine in the department of oral medicine at Penn Dental Medicine.

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This essay continues the series that began in the fall of 1994 as the joint creation of the College of Arts and Sciences, the Center for Teaching and Learning and the Lindback Society for Distinguished Teaching. 

See https://almanac.upenn.edu/talk-about-teaching-and-learning-archive for previous essays.