Nazli Hossain  ( Department of Obstetrics Gynecology, Dow Medical College, Karachi, Pakistan )

The subject of Biomedical ethics has no formal lectures or tutorials at postgraduate level. The subject was introduced in the form of interactive sessions, workshops and tutorials to the students in 2018. The first report of the teaching experience was published in a reputed ethics journal.¹ The process was continued in 2019 in the larger interest of the medical profession. During 2019, 11 sessions, including the introductory session by the Founding Chairperson of CBEC SIUT (Centre of Bioethics & Culture) were held at Professional Development Centre, Dow Medical College. The participants included residents from two Obstetrics & Gynaecology departments of Dow Medical College (Gyn Unit II &III), Medical Unit III and Surgical Unit 11, III and IV. The participants also included faculty members (Assistant Professor, Senior Registrar) from Paediatrics, Obstetrics and Surgery departments. This time we also had two residents from a neighbouring hospital of the district, Holy Family Hospital. One of the consultants from outpatient department of Civil Hospital also attended all sessions. The report of first course was published in Indian Journal of Medical Ethics.¹ The focus was on first year residents, in order to make them aware of basic concepts in Biomedical Ethics. Inclusion of faculty members from the same departments was done to bring them on the same level of the thought process. The sessions were held on first Thursday of each month (except for one session) at 9am. Majority of sessions were held for duration of one hour, except for sessions on medical error and negligence, research ethics that were held for 2 hours. The sessions were mainly interactive, with emphasis on participant's active inclusion in the case discussions. The main objectives of these sessions were:

• To introduce postgraduates about the four pillars of biomedical ethics (autonomy, justice, beneficence and nonmaleficience).
• To give them core knowledge about common ethical issues like informed consent, plagiarism.
• To introduce them to basic concept of research ethics and publication ethics.
• To provide framework for ethical relationship with pharmaceutical industry.

Tools used in introducing topics included:

• Centre of Bioethics & Culture Videos
• Video made by DUHS (Dow University of Health Sciences)
• Case scenarios from hospital practice

Also participants were emailed relevant literature, from time to time for personal readings. Some also included newspaper reports about malpractices of medical professionals.

The topics included were:

1. Introduction of Biomedical Ethics
2. Qualities of a good medical professional
3. Ethical Dilemma
4. Ethical aspects of Abortion
5. Informed Consent
6. Medical Error and Negligence
7. Use of Social media in Medical profession
8. Ethics of Physician and Pharma relationship
9. Research Ethics
10. Breaking Bad news
11. Ethics of treating patients with HIV & AIDS (This topic was done separately in view of current epidemic of HIV (Human immune deficiency virus), as well as refusal from medical professionals in providing treatments to these patients)
12. Bioethics in Clinical Practice.

The facilitators included faculty from CBEC, DUHS, AKUH (Aga Khan University Hospital) and renowned medical professionals like Dr Anwar Siddiqui and Dr Fatema Jawad. In the last session we will try to link clinical practice with core values of Biomedical ethics. For this topic, Dr Aamir Jafarey, Professor of Bioethics at CBEC, will deliver a talk and also share his experience of being trained in General Surgery and currently working as Professor of Bioethics. I also invited the participants to share their own experiences, if they were able to use the core knowledge in their clinical practice. The feedback on how the knowledge was utilized in clinical practice was encouraging. One of the residents shared her experience of delivering an unmarried girl, and using SPIKES model² (S stands for setting, P for perception, I for information, K for knowledge, E for empathy, and S for summarize) to break the news to the attendants, and how she kept privacy of the young girl. A surgeon shared her experience of how informed consent session helped her to obtain consent from parents about a difficult surgery. And after recovery, the grateful parents stay in touch with her till date, by sharing their son's photographs. The session on Ethical aspects of Abortion was very informative and first time I can correlate medical knowledge, law and sharia. Another participant wrote about the same session:

"Always heard Termination of pregnancy is equivalent to murdering in Islam. I came to know legal and Islamic ruling permissibility incase of saving maternal life and in 22 foetal conditions at gestation less than 19 weeks + 1 day. To refer patients to professionals in aborting unintended pregnancy to reduce septic abortions".

Regarding Medical negligence and error:

"Came to know that retained swab is a Medical Negligence but gut perforation while difficult access surgery is Medical Error. And to inform patient & attendants when such mishap occurs".

"I never knew how unethical it is to accept undue favours. I admit my friends accepted perks and me from the companies, including books, Iftar coupons, and many other things. Nobody ever told us that this is wrong, neither in my house job days nor in my residency period. How unethical it is to accept favours and promote their drugs. Definitely when you accept favours you get biased".

A participant captured expression from her patient, after attending Breaking Bad News session.

"One year back doctor said 'your baby is dead; today you said 'there is no heartbeat' though content of message is as unfavorable as it was one year back but these words were not that painful. This memory will live with me and it will half my emotional distress".

The dropout rate was significant. Ten participants dropped out in the beginning of the session. The reasons were residents moving abroad on scholarships, personal reasons, and unavoidable circumstances. As there is no definite way to examine students in Bioethics for such voluntary sessions, held on monthly basis, as a teacher one is at a disadvantage to know the impact of imparting knowledge to the medical residents. We did evaluate our participants at the end of every session with feedback forms, and also by informal communication, but there is no robust way to know how much information has been delivered. A change in practice and attitude of residents is expected, but it will be a long way to go. The changes are hard to come as well, since working in a government sector tertiary care hospital has its own shares of problems. I also strongly acknowledge the support extended by the staff and Director of Professional Development Centre in facilitating us, by providing us with stationary and printing materials. The participants were provided hand outs of the workshop on Medical error and negligence and Research Ethics. The activity was registered with the Professional Development Centre of Dow University, and participants were awarded CME (Continuing Medical Education) points according to the prescribed criteria of Pakistan Medical Council.

 

The Future

 

I intend to continue these sessions in the third consecutive year. Despite a number of setbacks (drop outs, head of departments refusing to allow their residents to attend, personal comments from faculty members of trying to become bioethics champion), I have faith in myself, my support team and God that there will be light at the end of the tunnel.

 

What will be new in the third year?

 

I intend to strengthen further the topic of Research Ethics. Currently, done in 2-hour session, it will be extended to 4 hours, as it includes not only good and ethical practices in conducting medical research, plagiarism, publication principles, and other related topics. Also to be introduced is End of Life issues, a topic that is not usually taught either at undergraduate or postgraduate levels. I intend to invite residents from neighboring hospitals and other medical and surgical units of the Civil Hospital, in order to create more awareness about Biomedical ethics. In order to decrease the dropouts, in the coming year, participants who were inducted in postgraduate training of July 2019 will only be included. Since inclusion of year 3and 4 residents result in increased dropout rates.

 

References

 

1. Hossain N. Teaching bioethics to postgraduate students in a public sector university: A report from Karachi, Pakistan. Indian J Med Ethics. 2019; 4:242-244. doi:10.20529/IJME.2019.034.

2. Abdul Hafidz MI, Zainudin LD. Breaking Bad News: An essential skill for doctors. Med J Malaysia. 2016; 71:26-27.