For the things we have to learn before we can do them, we learn by doing them.
Aristotle, Nicomachean Ethics Footnote 1
Introduction
Teaching healthcare ethics at the doctoral level presents a particular challenge. Students obtaining doctoral degrees in this field are predominantly bound for careers in academia, as clinical ethics consultants, and as executives in the healthcare industry. Required in such an education is a robust grounding in theory, but due to the applied nature of bioethics, students also require opportunities to develop relevant skills related to ethics consultation, as well as some introduction to the pathophysiology, diagnostics, therapeutics, and institutional–cultural aspects of medicine. In this paper, we explore the challenge of introducing students to the world of medicine in a concise way that is also memorable, intellectually substantial, and foundational.
It is common for ethics to be taught to medical students, but it is unusual for medicine to be taught to graduate students in healthcare ethics. In this paper, we describe a course—Medicine for Ethicists (MfE)—that is, taught both didactically and experientially. Students read a medical textbook, take challenging multiple-choice tests similar to ones found in medical schools, and are asked to explain clinical reasoning in front of their peers. It is not known how an experiential approach is viewed by students, but it is hypothesized that it is seen as valuable.
The field of bioethics is an interdisciplinary one. The ethical problems that arise in biomedicine are often situated at the confluences of medicine, law and business, and require the expertise, knowledge, and tools of these disciplines, plus those of philosophy, theology, and the humanities more broadly. It is a field that is positioned to achieve unique synergies in a world where people tend to become locked into path dependency on certain ways of knowing. In the University, where ways of knowing (specific epistemological methods, forms of validity, and scope) are embedded in one’s profession, these differences can often intensify, deepen, and calcify. The way that Professors of Surgery know, for example, is different than the way that Professors of Theology know. The challenge, therefore, is to provide the student with an education that is not limited by such path dependence. We have hypothesized that experiential education, or an education that proceeds by students actually doing and functioning in the world, rather than only studying about the world (an “experiential approach”), might be one way to achieve this and that it is important for students to learn not only something of what active clinicians know but also how they know.
Central to the theory of experiential education is John Dewey’s 1938 Experience and Education. Dewey describes a philosophy of education that relies entirely on social interaction: the only experience that humans can have is a social one. The concept of experiential education, therefore, emphasizes a deliberate enrichment of the social milieu of the student, in distinction to a more traditional approach of rules, facts, schedules, and procedures. Dewey describes a temporal distinction between present challenges and future challenges in his differentiation of experiential learning. The experiential approach brings current knowledge to bear on present challenges and the educational experience emerges from there, whereas in a traditional curriculum, new distinct knowledge is handed down in theoretical preparation for future challenges.Footnote 2
Experiential learning theory, a pedagogical approach developed by David Kolb which “emphasizes how experiences, including cognition, environmental factors and emotions, influence the learning process,”Footnote 3 suggests a four-stage cyclical model of knowledge development beginning in concrete experience. Literature suggests that various versions of experiential learning theory are being deployed regularly both in the ethics education of clinical trainees and in the training of clinical ethicists, themselves. Experiential learning approaches in the ethics education of clinical trainees focus on ways to expose learners to and equip them with the practical skills required for moral reflection and action, as well as effective interprofessional and patient–clinician communication. Typical approaches in this context include Moral Case DeliberationFootnote 4 , Footnote 5 and Ethics Reflection GroupsFootnote 6 (both of which involve collaborative and structured dialogue about professional ethical dilemmas), Problem-Based LearningFootnote 7 (in which students engage in self-directed, real-world problem solving in groups), and Simulated or Standardized Patient ExercisesFootnote 8 (which attempt to mimic a real patient encounter through role-play).
Experiential learning theory has also been applied to the formation of clinical ethicists, a profession that requires both the acquisition of certain knowledge and theory as well as the development of a set of practical skills including ethical assessment skills, process skills (e.g., identifying stakeholders, negotiating between competing worldviews, and collaborative problem-solving), and interpersonal skills (listening and communicating effectively, attending to relational barriers, and educating stakeholders).Footnote 9 Notably, the ASBH Core Competencies—a centerpiece document in the professionalization of clinical ethicists—argues that process and interpersonal skills are “acquired primarily by ‘doing’…and there is no substitute for the role of experience in their development.”Footnote 10 Experiential learning in the context of training ethicists is deployed through programmatic elements like service-learningFootnote 11 (in which students volunteer in healthcare related contexts), clinical simulation exercises (e.g., simulation of an ethics consult),Footnote 12 and internship experiencesFootnote 13 (which include clinical shadowing, reflection, and debriefing exercises).
Although these applications of experiential learning lack robust outcomes data, preliminary data suggest that experiential learning methods in the context of ethics education of clinical trainees and education of ethicists can be effective at achieving articulated learning outcomes.Footnote 14 Importantly, however, effectiveness is largely dependent on the availability of structured guidance, instructor and peer support systems, and opportunities for reflection and group debriefing. Returning to Kolb’s four-stage model of knowledge development, the concrete experience itself is only the first step of a multistage pedagogical process, which necessarily involves reflection, conceptualization and reconceptualization, and experimentation.Footnote 15
The experiential learning components utilized by the MfE course aimed primarily at exposing nonclinically trained ethics students to aspects of the concrete experience of medicine and medical education, which was achieved through elements like studying and being quizzed on the content of medical textbooks, role-playing clinical encounters, taking oral exams testing clinical reasoning skills, and producing a final paper on a clinical medicine topic grounded in evidence-based medicine.
To more fully elucidate how students perceive the distinctness and value of the experiential approach, open-ended interviews with students who have taken the course over a 3-year period (2016–2018) were conducted. The questions examined their views on the distinctness of this way of knowing, whether they viewed it as experiential, whether it was uncomfortable, whether it came easy to them, whether this way of knowing shapes the knowledge itself, or even whether it was tinged with a certain politics. In this paper, we present the results of these interviews.
The Course
The PhD program in Health Care Ethics at Saint Louis University is a 60-credit hour interdisciplinary degree program that includes graduate-level courses in various methods in bioethics (philosophy, theology, empirical methods, and scientific methods) as well as clinical ethics, research ethics, bioethics, and the law and a course called “Medicine for Ethicists.” In combination with the PhD practicum, another experiential learning course involving 150 hours of clinical shadowing and volunteer work, the Medicine for Ethicists course is designed to introduce nonclinically experienced graduate students to clinical medicine, including pathophysiology, diagnostics, therapeutics, and institutional–cultural aspects.
The course takes place in 2-hour sessions over the course of 8 weeks. Each class session involves a challenging five-question multiple-choice quiz, which covers an assigned reading. The two textbooks used for the course are ones used by students in medical training:
Papadakis M, McPhee S, Rabow MW, eds. CURRENT Medical Diagnosis and Treatment 2020. New York: McGraw-Hill Education; 2020
and
Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed. New York: McGraw-Hill Education; 2015
The course involves a series of 20 minute didactic lectures, covering topics from transplantation to health insurance. The students are also asked to respond to clinical scenarios in an approach that approximates the standard clinical encounter (e.g., the “ABCs” of emergency care and the History and Physical—albeit with no physical examination). The students are individually examined for their ability to choose the correct approach and describe how a clinician would conduct an encounter with a patient across a variety of circumstances.
Finally, the students are asked to immerse themselves in a natural experiment of history of bioethical importance that also has a rich evidence base, which allows for evidence-based medicine analysis. A 12–20 page paper is required, centering on some topic of ethics within this natural experiment and must include elements of evidence-based medicine. Previous paper topics have included: Xigris as a life-saving Drug for Use in Sepsis; Vaccine Creation for the Ebola Virus; and The FDA and the Approval of Avastin for Metastatic Breast Cancer.
Methods
Students who had been enrolled in the course “Medicine for Ethicists” at St. Louis University between 2016 and 2018 were contacted by email to ascertain interest, after the conclusion of the course. Informed consent was obtained. This study was approved by the Saint Louis University IRB.
Eight former MfE students were independently interviewed in a semi-structured, open-ended format regarding their experience in the experiential component of the course, Medicine for Ethicists. The location of the interview depended on the convenience of the student. All students chose a classroom in the building in close proximity to their offices.
The questions asked can be found in Appendix. Short answers were followed by interviewer prompts such as “Please tell me more about that” to elicit richer responses. Interviews were recorded and precise transcripts were made using the speech-to-text software Temi.com©, followed by careful refinement by J.D.K. Thorough member checking was performed. The interviewee’s transcript was sent to the interviewee in an encrypted format via email. Interviewees were then allowed to alter the transcript to clarify thoughts, to correct errors, and to provide further analysis and comment. Transcripts were then deidentified and given a numerical identifier (1–8).
A descriptive phenomenological analysis was then performed, the aim of which was to discover the “lived experience” of the study subjects. The focus was not on substantiating any one hypothesis with data, but to develop a substantial picture of the meaning of the experience from the first-person perspective. We were interested in just how these subjects experience and make meaning of their world.
The transcripts were reviewed independently (J.D.K. and E.S.) and an open coding system was developed. Through a process of meeting and dialogue, the two authors came to consensus on a group of final codes that we thought would lead to the most meaningful insights. The authors then reviewed the transcripts again, placing quotes into each of our codes and started exploring the nuance of each code. Over the course of several subsequent meetings, the authors attempted to solidify the key meaning of the quotes to enrich our concept of what the students were trying to say.
Emerging Themes
The authors’ coding system revealed 11 distinct themes in three broad categories: themes relating to the concrete aspects of the MfE course, themes relating to other aspects of graduate learning experience, and themes relating to the students’ past and future career experiences.
Themes Relating to Concrete Aspects of the Medicine for Ethicists Course
Textbook/Reading
The assigned course readings, which came from a common medical school textbook, were frequently referenced as a stressful and overwhelming component of the course. For PhD students without clinical training, the readings were “foreign” (3), “tedious” (5), “scary” (3), and “terrible” (1). Students struggled with the volume of memorization and several began to merely “skim” readings as a strategy to cut down on the time required to prepare for class.
Quizzes/Tests
The course content was punctuated by in-class quizzes covering the required readings and one oral exam examining students’ ability to respond to clinical scenarios, which was practiced in class. Students found the quizzes challenging and one student “did not even bother trying” (6) because the volume of information to learn was so intimidating. Other students remarked that despite how uncomfortable the quizzes were, they still found them to be a valuable experience. The oral exam was generally more enjoyable for students; one student remarked that “I remember being very nervous for my oral exam…[but] it was really fun, like… a memory, and bodily and intellectual [experience] It’s not just memorizing” (7).
Memorization
For students most commonly trained in humanities disciplines, the memorization required to do well on MfE course quizzes was almost uniformly experienced as difficult, and not enjoyable: “I hate memorizing things. I’m not good at it.” (1); “I’m having that experience of feeling like I’m drowning in the textbook” (3). The memorization component of the course also allowed students to better appreciate the effort of medical professionals and trainees: “it made me feel…very inadequate…and it made me really respect doctors’ ability to do this” (3).
Synthesis
Students were eager to talk about the various elements of the experiential component of the course, including reflections on writing the evidence-based medicine paper (“definitely put me in a place where I had to synthesize the experience” [5]), in-class discussion (“it was good for us, I think, to be a group of philosophers and theologians interviewing a doctor” [5]) and the patient scenarios that were presented (“it was very collaborative and we were conversational about it” [7]). Many students mentioned the room where the course took place and the large table that the students sat around. Most students gave a slightly negative connotation to the physical surrounding. One student commented on the “camaraderie” (6) present in the student population and another commented positively on the “environment” of the class and the fact that it was “helpful just to have somebody I can ask questions to in a safe space that I had somewhat of a relationship with us who wasn’t going to shame me for being like, ‘that’s a dumb question,’ you know, so…I also really valued that about the lecture part of your class” (8).
Themes Related to the Broader PhD Student Learning Experience
Modalities of learning
The majority of students recognized that the experiential components of the course were somehow distinct from the didactic components of the course, and other more traditional forms of education in other courses they had taken. Several students described the difference metaphorically: “it would be like being a theologian who is constantly reading about God and talking about God but never goes to church” (2) and “its like the difference between reading about dance and dancing” (2). The experiential mode was described by one student as “not so cognitive” (6) and several students noted its embodied nature and used lively language to describe this embodiment: “I felt like I was drowning,” (3) “irritating” (1), and “I would pass out” (8). It was common for students to reflect on past experiences as being preparatory for this course; several students who had a clinical background prior to the PhD program were thankful that they had such an experience because it made the challenge of this course less intense. Two students went further than past experience and wondered if it takes a certain type of person to succeed at a challenge like this.
One student contrasted the experiential component with the rest of the curriculum commenting that “We’re increasingly encouraged to distrust our sensate knowledge in a technological world. You know, we are, we are, we are trained to think, to distrust, to doubt…” and that it was a good thing to recognize that this is “a good thing to get over, to confront” (6).
Relationship to other parts of the PhD program curriculum
Students commonly related their Medicine for Ethicist course experience with other parts of the PhD program curriculum, especially the Practicum, which allows students to shadow clinicians in the clinical setting. The Medicine for Ethicists course was seen as providing a foundation for a clinical shadowing experience: “having that course [Medicine for Ethicists] and then doing practicum right after was really really helpful…because I do not have any sort of…medical or clinical background” (4). Students also saw a natural relationship and progression between a classroom-based course like Medicine for Ethicists and an experienced-based course like the Practicum: “whenever I see the experiential knowing in the context of the Medicine for Ethicists [course], I also automatically couple it with the… clinical observership stuff” (4).
“Sciences” and “humanities” as different but related disciplines
Many students drew a contrast between what was described as “scientific” or “factual” ways of knowing and learning and “humanistic” or “values-based” ways of knowing and learning. These disciplinary approaches were contrasted in terms of methodology, language, and culture (e.g., sciences emphasize factual memorization and humanities emphasize conceptual analysis), but they were also both recognized as playing essential roles in healthcare. For example, one student emphasized how difficult it was to hold both ways of knowing concurrently: “Just almost feeling like there was no room for anything in my head other than facts, like absorbing the facts. Right? And not [sic] having like space” (3). Another student discussed the importance of integrating values-based thinking with clinical education: “I would love to teach young doctors how to think—kind of the opposite of what you did [teaching medicine to ethicists]—think in the humanities way. This would benefit them enormously. It’s helpful in thinking about their experience of going through medical school and the kinds of learning that they are doing and just how different it is” (5). Another student emphasized the natural integration of scientific and humanistic aspects in clinical training: “In … medical textbooks, there’s this assumption that what’s being relayed are the facts and it’s separated from any sort of values and you know, deeper questions. But … in our program and me personally, I do not think you can so neatly separate the two” (4).
Themes Related to the Students’ Past and Future Career Experiences
Prior experience
Many students came in with knowledge and experiences that facilitated their acclimation to the unique content of the course. In particular, previous clinically related job experiences (e.g., chaplaincy, textbook editing, health insurance coding, and healthcare consulting) were seen as beneficial to the process of orienting to and feeling comfortable in the clinical context. Others saw their lack of background in medicine or science as a detriment: “[the course was] just foreign to me…because of my background. Some people have more scientific or social scientific background” (4).
Careers
Most students in MfE reflected on the impact the course might have on their future career in bioethics, careers that include clinical ethics jobs, academic positions, and teaching positions in undergraduate, graduate, nursing, and medical school contexts. Prominent in comments about students’ future careers was the desire to speak and be understood across disciplinary lines, specifically in the clinical context. “I think the more that I, as an ethicist, can understand kind of where they are coming from and…how they learn, how they think, like that might help in communication and building trust. I think that’s…very helpful. Very valuable” (7). “The last thing I want is for clinicians to perceive me as annoying or not having anything to offer in a clinical encounter” (3).
Empathy for and understanding of clinician experience
Several students (5 out of 8) discussed the impact the course, and specifically the use of the medical textbook, had on their ability to empathize with and potentially better understand the experience of medical professionals and trainees. Example articulations of this sentiment “…it also gave me a kind of empathy for the doctors” (1), “and I kind of knew this before from [sic] my friends who have gone through nursing and med school, just how much memorization it is” (5); “in that sense it gives you access to those emotions and feelings of what it might be like to be a physician or a med student…” (8); “It made me feel, um, very inadequate…and it made me really respect doctors’ ability to do this. I mean, I just cannot even imagine. I mean you would have to just be completely devoted to this just to get [sic] this information in your head” (3). Empathy and understanding were described both for medical trainees (e.g., the rigor of such a large volume of memorization) and for experienced clinicians (e.g., insight into the physician’s way of thinking through a clinical scenario) and served several interrelated purposes for students, including developing respect for and rapport with clinicians and clinician trainees.
Theology
Many of the students in the course reported a background in theology. When asked about the experiential component of the course, these students routinely expressed some “comfort” with the concept, comparing the idea to experiential knowing in that field. One student asked rhetorically, “how can you know a subject matter unless you really live it out to a certain extent?” (2). Another, when discussing the difference between simply reading about it and actually doing it stated, “you could get the idea, but you are not going to really know it in that deep sense” (6). Finally, one student made the following summative statement: “I am a big proponent of experiential learning” (2) and rooted the statement in prior familiarity with the concept in theology.
Discussion
There is a chasm between the way that healthcare ethicists learn and know and the way that physicians learn and know, yet in a well-functioning contemporary healthcare system both ethicists and physicians need to work together in a mutually reinforcing way. Experiential teaching in both groups may be one way to lessen the divide.
The purpose of this study was to understand perspectives of healthcare ethics graduate students taking the MfE course in a detailed way when it comes to the experiential component of the course. The students in this study seemed to find that there was a distinct experiential component that could be discerned from the rest of the class material. They also found the experiential component to be distinct from the rest of their graduate and their remembered undergraduate experience, except in cases where their prior experiences had been clinical.
Experiential learning is a well-developed concept in educational theory. Aside from the earliest Aristotelian inclination toward the concept, other contemporaries of Dewey are credited with developing the concept, including Jean Piaget and Kurt Lewin. According to David Kolb, whose 1984 book Experiential Learning is often considered foundational, descendent branches and trends of experiential learning can be found in the psychoanalytic work of Carl Jung and Eric Erikson, humanistic psychology through Carl Rogers and Abraham Maslow and finally “radical” educational theorists Paulo Freire and Ivan Illich.Footnote 16 This analysis has been critiqued as being “eclectic.”Footnote 17
In our study, we use Dewey’s theory as a primary source of inspiration and do not attempt to engage this more contemporary frame of educational thought. As Roger Greenaway has explained, “Dewey provides a broader vision of ‘educative experience’ than many of his followers do. Dewey’s interest was in the kinds of experiences that arouse, that are intense, that strengthen, that stimulate, and that live on in future experiences that have similar properties (p. 365).”Footnote 18
The portrayal here of experiential learning is peculiar since the students’ other classes, with the exception of the required PhD practicum, are primarily taught dialogically and interactionally. These are primarily humanities students and, though subject to knowledge requirements, are most commonly evaluated on their abilities to reason, articulate and analyze complex concepts and engage in discursive thought. This may be one of the first instances in the literature that attempts to understand student perceptions of integrating an experiential component to an otherwise theoretical course of study.
Particularly notable was that most students described the “embodied” nature of the experiential component when referencing the class. Many students commented on both the physical surroundings, the close camaraderie between the students, partially as a function of the space, and offered an array of memories of guttural reactions to the experiential challenges put before them. The reasons why the students described their experiences in terms of embodiment were elusive. Was it because of the “otherness” of the experience? Was it because the material explored was itself about bodies, or some other reason? This would be an interesting avenue of future investigation.
Another notable finding was the extent to which this course exposed nonclinically trained ethics students to experience—in small doses—the type of training required by medical students and nursing students, and the extent to which this experience catalyzed in them an empathy and respect for clinicians. For example, one student commented that “they have [clinicians] got a lot of pressures and I knew just observing them from before, but if this is the way they have to do it, it made me feel worse” (1). Of their future career in clinical ethics, another student remarked that “this class will be really helpful…in terms of thinking like a doctor, relating to a doctor, relating to patients, gaining my own self-awareness of how overwhelmed I get sometimes with the medical system, building empathy” (8).
These comments reflect a larger conversation about how clinical ethicist “outsiders” (typically, academics trained in the humanities) do or should relate to clinical “insiders” (practicing clinicians) in the context of ethical dilemmas or conflicts.Footnote 19 Bioethics, as a field, emerged largely as a movement critiquing the historical paternalism of the medical profession and continues to critique and hold accountable the training and practice of clinicians.Footnote 20 In some cases, the “outsider” status of a clinical ethicist was seen as an asset: “many of these pioneer clinical ethicists believed their insights were particularly valuable precisely because they were outsiders and thus more unbiased than the ‘insiders’ at the bedside.”Footnote 21 However, the outsider status of nonclinically trained ethicists can also be seen as a liability. Perhaps most notably, physician-ethicist Mark Siegler has argued that humanists can play only a limited role in clinical decision-making.Footnote 22 Thus, today’s healthcare ethicists must negotiate the tension between the risks and benefits of being nonclinical enough to maintain the critical distance required for perceptive critique but clinical enough to understand, relate to and empathize with the experience of clinicians. The MfE course is concerned not only with the didactic tasks of conveying knowledge of the clinical context (e.g., medical terminology, basic diagnostic and prognostic reasoning techniques, technological, and therapeutic approaches to disease) but also the experiential and relational tasks of understanding and relating to clinically trained colleagues.
There is a risk that the results in this study were biased. We endeavored to focus the interviews on the experiential component of the course and attempted to do it in a value-neutral way; however, the way the questions were asked may have induced bias. This was an optional study—there were other students that did not sit for an interview. Interviewing students who did not self-select to sit for an interview might have yielded different results, especially about the overall positive valence of the responses. Finally, the interviewer was the instructor for the course. As of the writing of this paper, the instructor has no future plans to teach these students, since his primary appointment is in a different school (the School of Medicine). Despite this, the students could certainly have altered their responses when compared to an imaginary interviewer they had never met before.
Conclusions
Interviews with former students suggest that the experiential learning components of the MfE course offered learning opportunities that were both valuable and unique in the context of their training as scholar-practitioners of healthcare ethics. Students were introduced both to the content of clinical knowledge (the “what”) and the specific modes of learning and knowing that characterize clinical medicine (the “how”). The experiential aspects of the course were described as both valuable to the students’ specific career goals (e.g., being able to communicate with clinicians as a clinical ethicist)and valuable toward the more expansive goal of reintegrating academic disciplinary silos.
The more theoretical the students got, the more their responses seemed to suggest broader implications. The idea that there is a deep divide between the way that students of the humanities learn and know and the way that students of medicine learn and know are not limited to humanities and medicine. We offer that this division is congruent with many deep divisions that are pervasive throughout society. Insight into just how ways of learning and knowing can differ between social groups should be sought in addition to what individuals in these groups know. Future work could focus on both expansion of and developing evidence for other pedagogical approaches to teaching medicine to bioethicists, but could also focus on the broader implication of better understanding.
Conflict of Interest
The authors declare no conflicts of interest.
Appendix
The Interview Script
Please remember back to your time in the Medicine for Ethicists course. I designed the course to include some “experiential” components, including reading a medical textbook, taking challenging multiple-choice tests, and asking you to explain your clinical reasoning in front of your peers. We also challenged you to analyze scientific articles using “evidence-based medicine” approach.
Please summarize the experience to the best of your ability, with reference to the physical surroundings, the objects, the people involved and their relationships, the social interactions between the different characters (or groups), the type of activity, the outcome, the descriptive elements, the time reference, and the emotions, beliefs, attitudes, or plans.
Now, I have a series of questions for you—please give me a detailed response to the following questions, if you can:
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Is this a distinct way of knowing?
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Is this an experiential or phenomenological way of knowing?
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Is this way of knowing uncomfortable?
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Does this way of knowing come easy to you?
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Does this way of knowing seem to shape the knowledge itself?
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Is this way of knowing tinged with a certain politics?
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Do you see it valuable for your future career?
Thank you for your participation today.
