Ethics consultants get doses of realism through simulations

Chicago -- It's a relatively simple case, Dr. Murphy told the ethics consultants he met with in June. A Spanish-speaking, 65-year-old woman of Mexican descent presented with a large growth in the soft tissue of her lower torso. He suspected it might be cancer and wanted to order a biopsy, but was worried the woman's daughter -- who handled interpreting duties -- would try to shelter her mother from the bad news.

"It's crazy," Dr. Murphy said. The patient "needs to be involved in her own health care decisions at some level."

When the daughter, Ines, stepped in to meet with the same ethics consultants, Michael Bliss and Jeffrey Loebl, tension filled the room.

"I know how she is," Ines said of her mother. "When my dad was really ill -- he had cancer -- she used to say to me all the time, 'You shouldn't tell someone they have cancer.' She's right. Knowing that information doesn't help you get better."

The case represented a clash of cultures. On one side was Dr. Murphy's medical culture of patient autonomy; on the other was the patient's cultural preference to be left in the dark. Slapped on top was a healthy dose of strained relations that left the ethics consultants flummoxed on how to satisfy everyone.

Perhaps it's a good thing the scenario was just pretend.

Ines was an actor employed as a standardized patient to help train bioethicists in the practical skills they need to mediate conflicts among physicians, patients and families while determining the right ethical and legal course. Dr. Murphy was played by Kayhan Parsi, PhD, graduate program director of the Loyola University Chicago Stritch School of Medicine's Neiswanger Institute of Bioethics & Health Policy. And the whole thing was videotaped for consultants Bliss and Loebl to analyze once the three days of role-playing exercises concluded.

While medical schools have been using standardized patients to help train doctors since the 1960s, Loyola is among a handful of North American bioethics programs employing these actors to simulate conflicts for ethics consultants. Others include the University of Toronto Joint Centre for Bioethics; Alden March Bioethics Institute in Albany, N.Y.; and Union Graduate College-Mt. Sinai School of Medicine Bioethics Program in Schenectady, N.Y. In the simulations, students learn to gather the medical facts of a case, conduct productive conferences with doctors and families, and recommend ethically acceptable options.

This training appears to be in need. Eight in 10 hospitals offer some kind of ethics consultation service, and all hospitals with more than 400 beds do so. But only 5% of consultants have completed a fellowship or graduate degree program, and less than half have more than five years' experience on the job, according to a February 2007 American Journal of Bioethics study. Meanwhile, a March 2004 Journal of General Internal Medicine survey found that four in 10 physicians are reluctant to ask for ethics advice because they are unsure it will help.

Not much on-the-job training

The typical ethics committee handles only three consultations a year, so chances to learn on the job are few. Funding for training is erratic. Most students pay their own way through Loyola's mostly online program, pursuing certificates or master's degrees in bioethics.

Parsi said the on-site simulations seminar, offered annually by Loyola since 2004, is surprisingly realistic.

"You know intellectually this is not real, but the standardized patients are really good," Parsi said. "The emotions you feel are real. Otherwise, it wouldn't be a consultation. That is part of the dread people may feel. That is why you get that pit in your stomach. These are very difficult conversations to have with people you don't know. ... If you've never done these and you go in cold, there is a sense of, 'What am I doing here? What can I offer these people?' "

Robert Baker, PhD, is director of the Union Graduate College bioethics program, which also does ethics consult simulations. He said they are critical to improving ethics outcomes.

"We're using some sophisticated methods to train people to be clinical ethicists and research ethicists," Baker said. "It cannot be the case that the only nonprofessional group of people working in a hospital are the ethicists. The ethics people have to be just as competent, just as professional and just as well-trained as everybody else in the health care setting."

Baker sits on a committee recently formed by the American Society of Bioethics and Humanities, the organization that represents clinical bioethicists, to examine what, if any, training should be required of ethics consultants.

The American Medical Association has no policy on credentialing ethics consultants but says hospitals should provide and finance access to consultations, which should follow explicit procedural and structural standards. AMA policy also says doctors should be paid for doing clinical ethics consults.

Even experienced consultants -- about 30% of this year's Loyola class -- find the ethics consult training exercise helpful.

"In my particular situation we had a very diminutive actress, but she intimidated me right off the bat," said P.D. Bullard, MD, an ob-gyn who serves on the ethics committee at the Lexington Medical Center in West Columbia, S.C. "She was a very aggressive caretaker for her mother."

Dr. Bullard said he felt obliged to improve his skills.

"There's no credentialing," he said of the bioethics field. "You can hang out a sign and say, 'I do ethics consults.' But are you doing a good job? ... I thought I was doing a pretty good job, but I thought I could do a better job by getting better expertise."