381approaches for an innovative ethics curriculum would utilize a combination of edu-
cational strategies chosen to complement specific content and learning objectives.
Such approach might still center on case-based learning events, but also use addi-
tional teaching modalities that may better address specific goals and objectives. For
instance, conceptual learning could be supplemented by short didactic sessions or
videos provided for independent study. Examples of topics are included in Box
21.1. Modules for learning ethical principles could be integrated into clinical rota-
tions such as breast oncology (e.g., genetic testing), transplantation (e.g., distribu-
tive justice), thoracic (e.g., innovation), and trauma (e.g., competence and surrogate
decision-making), making the material more immediately relevant to the learner.
Assessment may be enhanced by evaluating competencies within a virtue-ethics-
based framework that emphasizes caring for the patient as a primary goal [ 18 ]. Brief
oral exams for assessment and feedback can be initiated by a designated instructor
within each rotation and integrated into the resident’s portfolio to allow for achieve-
ment of Next Accreditation System milestones [ 22 ]. OSCEs focusing on ethics
principles can also be designed to capitalize instances when learners are already in
technical skills simulation sessions.
One example of this approach has been implemented during the Southern Illinois
University (SIU) surgical resident readiness course designed for fourth year medical
students with interest in entering a career in surgery. In their first week, students are
instructed on the processes of informed consent through a didactic lecture that cov-
ers topics ranging from establishing the doctor-patient relationship to professional
norms including documentation of operative notes and consent discussions.
Subsequently, during their curriculum, they are asked to simulate these conversa-
tions with their partner prior to performance of procedures in a cadaveric skills lab.
During a PGY2 “Residents as Teachers” curriculum, SIU residents participate in
didactic lectures on teaching followed by three hands-on sessions where they pro-
vide supervised sign-out of multiple patients to a colleague and obtain and critique
performance of informed consent for placement of a central line, followed by teach-
ing a colleague on how to place a central line using a patient simulator. In these
scenarios, the processes of how to communicate well with others become important
areas for self-evaluation and peer-to-peer feedback. Through a change in context
and perspective with the learner, we allow informed consent to transition from a
low-level task “checked off” prior to operating to a necessary process element of
fundamental importance for establishing the surgeon-patient relationship.
Optimally, ethics education ought to be provided at multiple time points of train-
ing so that the learner can build upon and reflect on prior knowledge and experi-
ences and engage in a transformative learning experience. In a longitudinal fashion,
teaching and assessing confidence in informed consent could be part of a multilevel
simulation curriculum, allowing for assessments before a PGY1 places a central
line in a patient simulator, at the PGY2 level when they use a colonoscopy simula-
tor, or at the PGY3 level when they rehearse for Fundamentals of Laparoscopic
Surgery testing.
Written narrative reflection may also help residents process the emotional aspects
of dealing with conflicts and dilemmas they encounter longitudinally during resi-
dency [ 23 ]. Written self-reflections of ethical dilemmas encountered by the resident
21 Teaching Surgical Ethics