Teaching of Medical Ethics : Students ’ perception in different periods of the course

Background: Medical Ethics is structured to guide doctors towards a better professional practice. However, its teaching in medical schools seems to be neglected. Aim: To evaluate the perception of Federal University of Sergipe medical students about ethical confl icts during their academic practice, in two different periods of a medical course. Material and Methods: A cross-sectional, analytic and observational study. Using a qualitative approach, analytic categories were identifi ed using an open questionnaire answered by two groups of students, before and after attending the medical ethics course. Results: In everyday practice, the participants referred embarrassment in front of patients. When considering the relationship with the professional/professor, they identifi ed negligence and confl icts of interests in their practice. The students also detected bad infrastructure and professional relationship in public services, when compared to private ones. The confl icts experienced by the students in their own practice were insecurity, inability to cope with patients’ problems and inadequate perception of medical confi dentiality limits. According to the respondents, contribution of ethics teaching varied from adequate, when it was effective to orient their practice and provide confi dence, to inadequate or absent because of an overall superfi cial approach. Conclusions: Major defi ciencies related to the teaching of medical ethics were identifi ed, pointing to the need to change current medical education model. (Rev Med Chile 2010; 139: 36-44).

The problem H uman behavior is a complex entity, and regulations and laws have always been conceived to guide men's behavior in accordance to what is expected for one specifi c society.Since Hippocrates, medicine practice has expressed formal concern about moral procedures and respect for life.These were the beginnings of Medical Ethics.
The medical professional is subjected to preestablished ethical standards that guide his/her conduct in the different activities he/she may be exposed, and ethical discussions have been included as a specifi c discipline in the medical course curriculum in some, but not all universities 1,2 .
Ethics and moral are complementary terms.Ethics, from the Greek ethos, means "way of being", "character" and moral, from the Latin mor or moris, means "usual", i.e., a set of standards or rules acquired by man by ordinary use 3,4 .
Professional Ethics or Deontology includes the guiding principles for professionals when interacting with patients, other professionals and the institutions where they work.These principles are limited to professional environment and have specifi c standards, such as the Brazilian Medical Ethics Code, established from discussions between doctors and society and approved by the Federal Council of Medicine 2,5,6 .
For some authors 1 , the concept of Medical Ethics should prioritize medical practice.They understand that the Medical Ethics Code is no longer enough to guide the physician behavior.In an increasingly complex society, medical decisions go beyond purely cognitive aspects, so overrated in academia.It seems crucial to focus on medical education for ethics topics inclusion, inserting most of the problems students will potentially face during professional life 7 .Technical skills must be accompanied by ethical values early in medical education.
It is known that in many universities in Brazil, in their traditional medical course curriculum, Bioethics is not yet included as a discipline to guide the acquisition of abilities that allow the student to identify and analyze ethical problems yet.Only some of these themes are included in the subject of Forensic Medicine and Deontology, which prioritizes the Medical Ethics Code and the legal aspects of medical practice.Perhaps these contents are not suffi cient to fulfi ll the needs of students relating to the ethical confl icts in their academic practice.
Therefore, a research was made to identify how medical students deal with ethical confl icts before and after the formal teaching about Medical Ethics at the discipline of Forensic Medicine and Deontology; to identify situations of ethical confl icts during the academic practice and to verify the contribution of Ethics formal courses to dealing with these confl icts.
As well, this paper, as a clipping of this research, aims only to identify the perception of Federal University of Sergipe medical students about ethical confl icts during their academic practice, in two different periods of the course.

The method
This is a cross-sectional study in regard to the Medical Ethics teaching at the Medical School of Federal University of Sergipe (UFS), in Aracaju, Brazil.An open questionnaire was used, with 19 questions regarding subjects of students' studies, motivations, methodology, disciplines that contributed to the practice experience, and ethical dilemmas they could have experienced during the course.Acerca de su relación con los profesores, notaron negligencia y confl ictos de intereses en su práctica.Los alumnos también detectaron una mala infraestructura y relación entre profesionales en servicios públicos, al ser comparados con clínicas privadas.Los confl ictos que relataron los alumnos fueron inseguridad, incapacidad de enfrentar con los problemas de los pacientes y una percepción inadecuada de la confi dencialidad médica.Los alumnos consideraron que la contribución de enseñar ética fl uctuó desde ser adecuada cuando orientó su práctica profesional y les dio confi anza hasta inadecuada o ausente, debido a ser enseñada en forma superfi cial.Conclusiones: Se identifi caron las principales defi ciencias en la enseñanza de ética médica, señalando la necesidad de cambiar el modelo educacional utilizado actualmente.
The study was performed with two groups of students, corresponding to two different context units: the fi rst one, attending the 5 th and 6 th semesters, with students who had not studied the Forensic Medicine and Deontology, and the second one, attending the 9th and 10th semesters with students who had just fi nished that course.The same questionnaire was applied to both groups.
The discipline Forensic Medicine and Deontology was used as a landmark for the division of the groups, since it is the only one that formally approaches ethical contents.
The students participated in the classroom, where they received the questionnair, and those who agreed to participate in the research returned it to a predetermined local.
The present article used data from a single question that asked the students to write a brief story about the most important ethical confl icts perceived in their academic practice.
This study was approved by the Research Ethics Committee of the Federal University of Sergipe and all respondents were informed about the purposes of the research and about their rights, in accordance to the regulations for research in human beings 8 .
The total number of questionnaires returned was 110 (71.4%): 56 from the fi rst group and 54 from the second.
The fi rst group of students was formed by 24 women and 32 men, with an age range of 19 to 27 years and mean age of 22.3 years.The second group was formed by 22 women, 31 men and one respondent who did not declare the gender, with an age range of 20 to 41 years and mean age of 24.47 years.
Data was analyzed using a technique of categorical approach of content analysis 9 .Individual analysis was blinded by using a strategy in which each questionnaire was coded as A or B for the fi rst and second groups respectively and a sequential number for the students in each group.Content analysis was performed 9 , and each sense nucleus was identifi ed at the registry units (words, clips of speeches), leading to the analytical pre-categories.The resulting categories were grouped by similarity and registered with their sense nucleus, regarding to those categories presence in different contexts and not to their frequency of occurrence.

Results
In view of the ethical confl icts identifi ed by the student of both groups, the results were organized into four analysis sub-categories: 1. Confl icts involving the patient (Table 1); 2. Confl icts involving the professional / professor (Table 2); 3. Confl icts involving the structure of services (Table 3); 4. Confl icts involving their condition as students (Table 4).

Discussion
Frequently the relationship student-patient has been considered merely technical, depersonalized and sometimes troubled, bringing negative stress to the student.It was observed (Table 1) a similarity between the two groups regarding these confl icts, either with the student´s acts invading the patient´s privacy or when they are victims of patient´s violence or harassment.
The results of the present research are, most of the time, coincident with the ones of other authors cited in literature.
In these two context units, the contact with patients resulted in confl icts at some point during medical training.Students demonstrated a variety of fears while relating to the patient, probably due to lack of experience and insecurity in medical practice [10][11][12] .
For students in the 5th and 6th semesters, it seems to be more signifi cant, for collecting the fi rst medical history and performing the fi rst physical examination usually awake emotional reactions in students and make them anxious 12,13 : Feeling of bothering the patient, insecurity and diffi culty to examine the patient when it is necessary to undress him (A11, 5).
The feeling of using the patient as an object for study is also named as a nuisance to the students, creating feelings of being invasive or abusive to their fellow-being [11][12][13][14] : Patients were also a source of confl ict for having hostile attitudes when facing different situations.It seems to refl ect changes in society, where patients are not as "patient" as before 15 .Real life shows that the patient out of the books is a human being who suffers, complains, does not always cooperate and requires a quick and effective solution for his/her problems 16 :

I was threatened by a patient for delaying to attend him. I was almost beaten (A8, 6).
The results show that the interaction with various professionals allows having experiences in many types of confl icts, particularly as mutual respect, which is missing in medical education.In the two contexts units we found an inadequate attitude of professional/ professor, regarding to the relationship with patients.In second unit, however, students made it clearer, perhaps because they have already been exposed to specifi c discussions about that topic (Table 2).
Overcoming these diffi culties relies on the professor's aid, because it is during academic background that the students must obtain the resources they need to deal with human dimension of therapeutic relationship.A professor's example seems to be essential in building up professional identity, which enhances the patient-doctor relationship (10) .However, important confl icts involving professors were observed.There are unethical and inhuman attitudes by health professionals in general and by professors, and these models are incorporated into the student's practices as a standard for their professional behavior 7,15 .Some professors do not consider patient autonomy 17,18 and do not act within recommended ethical and humanistic approaches: In the investigation of certain conditions, it is not questioned whether the patient wants to be submitted to that procedure (A11, 9). .

.. professors seem to forget that they are facing the patients and talk about the disease (...) without caring about the human being in front of them (A22, 10).
In regard to that situation, some authors [18][19][20] report patient perceptions about the treatment received at the University Hospitals and reveal that the visits at the bedside are the only negative aspect, once they feel themselves like subjects under study.There must be ways to teach new doctors without embarrassing the patient.On the other hand, there are researches in which the patients relate they accept the student's presence in anamnesis as well as in the physical examination, as long as they do not participate in the decisions at diagnosis and treatment 11 .
Situations of abuse, defi ned as "negative actions or words, unnecessary and avoidable, infl icted by one person to another or others" (21) were indirectly referred, but such circumstances are very common, and literature 21,22 refers that many students reported abuse at some time point at the course.

… the occurrence of maltreatment of patients and students from professors (A1, 5).
Teachers` lack of compromise is also referred by students.They identify professors without updated teaching material, showing uncommitment to teaching process and frustrating student expectations about school contribution to their medical career with interesting and motivating teaching situations 10,23 : Some (professors) were arrogant, pretending they were almighty, without compromise with education (A3, 9).... arrived late or missed the clinic (A 21.9).
The relationship within the workplace was perceived as unethical and marked by a spirit of competition (24) : Authoritarian personality towards other professionals (A18, 5 ).
Professors do not miss any opportunity to lower a workfellow's image (A7, 9).
Interest conflict was identified by second unit students, referring to the infl uence of nontechnical factors in medical prescriptions (25)(26)(27) and mercantilist attitude of some professionals (28) : Doctors prescribe only one type of medicine and receive privileges from laboratories, like free travel to medical conventions, help in job dispute between professionals, patient referral to their private offi ces ... (A19, 9).
In this context, learning motivation can be infl uenced by the professor and the existence of confl icts in this relationship may cause depression and discouragement to studying and having a good relationship with patients 13 : My doctor ideal, as a person who is concerned about others' suffering, does not exist here.Doctors are insensitive.Patients are treated in an inhuman way.I see ethics as respecting the patient as a human being, and not as legal principles.Medicine has become a profession like any other (A32, 6).
The authors 21 remind us that when the professor gives some freedom, security and confi dence to the students, they feel more stimulated, while the aggressive response from him would be an obstacle to learning.
The students point out the lack of physical and organizational structure observed in public services and their anxieties about the quality of learning, considering the usual shortage of conditions for implementing knowledge.Also here, students of second unit relate problems more clearly, even identifying the care provided by unsupervised students (Table 3).
Medical schools should provide an infrastructure with adequate materials and professors committed to guide, encourage and foster students' learning based on humanism and ethics 23 .The overall situation is, inversely, the lack of commitment of professors and of hospital infrastructure to face student needs and aspirations 29 : In addition, the respondents have confl icts with their role as a student.
As medical students, they may fear specifi c responsibilities that they are not prepared to deal with.This may be a matter of lack of experience or technical skills, or it may happen because of shyness (Table 4).
The expectation to be a good doctor stumbles on the frightening prospect of increasing responsibility associated with the fear of making mistakes or not knowing what to do in the face of several situations 12,23 : The relationship with patients' relatives is sometimes interpreted as an obstacle to a good relationship with the patient: When the accompanist does not allow the patient to express by him/herself or when he/she inquires us about what the patient told us (A12, 9).
Facing death brings suffering, the students become aware or discover that it cannot always be avoided.The contact with chronic or terminal patients awakens in students a sense of impotence, and they realize that they do not really know how to deal with these situations 12,13,30 : ... to learn how to deal with children suffering from cancer and poor prognosis (A21, 10).
Doubts about the confi dentiality, body of character substantive in the doctor-patient relation (24) , created discomfort for some students: Patient who refuses medical recommendations and I did not know whether to inform the doctor, as the patient only told me secretly.(A1, 6).
Patient with AIDS accompanied by the husband, whom doesn't know about it (A5, 9).
The current individualistic vision discourages a listening attitude in daily relationships and makes doctors less prepared to work with subjectivity, and to develop a healthy doctor-patient relationship 31 . .

.. knowing to what extent we may/must get involved with patients' problems (A26, 9).
There are also diffi culties in understanding the patient, and it is important for the doctor to try to translate their language, sometimes full of primitive signs 31,32 .
Finally, the results also show how some subjects, according to the students, clarifi ed some ethical points, and were able to solve problems during the course 33 .
In general, for the fi rst group important relief could be felt in knowing that they are not the only ones with confl icts, that some confl icts are expected, indeed.
For the other group the guidelines are more detailed according to each situation, with some theoretical deepening missing, and some practical skills also.
There were students who did not feel assisted, in any way, by the institution with the confl icts they had to deal with, describing the school's contributions as insuffi cient or nonexistent.
It was observed that the teaching of ethics, as from the point of view purely deontological or understood as a guideline for dealing with moral confl icts of medical practice, constitutes a little explored fi eld within the university, despite its great importance.
Meanwhile, society requires more and more that doctors should have ethical attitudes and a holistic view of the patient, beyond the technical training so stimulated during their course.
The failing in the ethics formation within the university brings confl icts of the magnitude previously reported.The relationships in all fi elds, are worn, and students, most of the time, feel helpless.
The results show major defi ciencies in many respects, although a more sharp ethical conscience was evident in students from the second group, who studied Forensic Medicine and Deontology.They more often felt that they were more skilled to manage confl icts after having studied this discipline, also considering that different levels, age, and other variables must give different perceptions and experiences.
It is important to consider that the drawing of the study with different groups does not follow the maturation of the pupils throughout the course.As well, despite it is known that the students of the fi rst group were younger and less mature than the ones of the second group, and that these factors can infl uence their perception and administration of confl icts, what is argued in this paper is that there is no preparation of the pupils of the fi rst group about ethical considerations to face academic practice and patients contact, and this contact happens before they are prepared for this.
As for the second group, neither the subject Forensic Medicine and Deontology fulfi ls the students needs, because it is not a Bioethics specifi c matter, pointing to the need of Medicines courses, which have that matter as the only possibility of study of ethical subjects, to try to adjust its courses of study to contribute to the formation of the pupils and their future practice.
It is in progress another stage of the same research to identify, with the medical professionals, the confl icts in their practice and the contribution that the university education had to dealing with these confl icts.
Ahead of the results presented in this research, it is strengthened that there is an urgent need for greater commitment with education focused on the humanization of medical practice, with more prepared professors, better infrastructure and a curriculum reform that will prioritize the teaching of ethics.

Table 1 .
Ethical conflicts involving the patient identified by students, during the medical course

Table 2 .
Ethical conflicts involving the professional/professor identified by students, during the medical course

Table 3 .
Ethical Conflicts identified by students, during the Medical course, involving the structure of services

Table 4 .
Ethical Conflicts identified by students, during the Medical course, involving their condition as students