Task Force on Ethics and Professionalism

Understanding Sexual Victimization

• Introduction

  Sexual victimization is unfortunately an occurrence every medical practitioner will encounter. Further, recent events have demonstrated that medical providers themselves occasionally prey on the vulnerability of patients. It is essential, though uncommon, that students in training have the knowledge, skills and attitudes needed to address victimization across the lifespan and use trauma informed care principles to best provide appropriate, compassionate and holistic care. This set of resources can help set the stage for such conversations and curricula.

• A. Psychology of Victimization

  1. Identification

  1. Define victimization
  2. List psychological consequences of victimization
  3. Explain the concept of complex personhood in the physician-patient relationship

  2. Stages of trauma/recovery

  1. Describe the core stages of trauma: helplessness, isolation, loss of power and control
  2. State the barriers to disclosure by trauma harmed
  3. Describe trauma-informed care and vision ways to implement within medical practice

• B. Sexual Victimization and Violence Across the Lifespan

  1. Screening for sexual or other physical violence

  a) Describe protocols for screening for abuse across the lifespan

  b) Compare and contrast violence against: children, intimate partners, elders, persons with disabilities

  c) Describe direct and indirect methods of screening for sexual abuse  

  d) Discuss duty to report

  e) Identify appropriate referral for collection of evidence and treatment

  f) Describe indicators of human trafficking victim behavior

  2. Long term sequelae for sexual assault and victimization

  a) Describe psychological impact on assault survivors

  b) Discuss gender differences in psychological outcomes following victimization 

• Selected Resources

  • AACAP: Overview of Child Sexual Abuse (CSA)
  • NCTSN: Evidence-based treatment of trauma
  • WHO: Overview of CSA
  • CDC: Preventing CSA
    Kennedy K (2014) The case in favour of educating medical students about sexual violence, Medical Teacher, 36:3, 267-268, DOI: 10.3109/0142159X.2014.875618
  • The Case in Favour of Educating Medical Students About Sexual Violence
    Kennedy KM , Vellinga A, Bonner N, Stewart B, McGrath D (2013) How teaching on the care of the victim of sexual violence alters undergraduate medical students' awareness of the key issues involved in patient care and their attitudes to such patients. Journal of Forensic and Legal Medicine, 20 (6) 582-587.
  • How Teaching on the Care of the Victim of Sexual Violence Alters Undergraduate Medical Students' Awareness of the Key Issues Involved in Patient Care and Their Attitudes to Such Patients
    Brown, Taylor; Berman, Sarah; McDaniel, Katherine MSc; Radford, Caitlin; Mehta, Pooja MD; Potter, Jennifer MD; Hirsh, David A. MD Trauma-Informed Medical Education (TIME), Academic Medicine: July 14, 2020 - Volume Publish Ahead of Print - Issue -doi: 10.1097/ACM.0000000000003587
  • Trauma-Informed Care as a Universal Precaution: Beyond the Adverse Childhood Experiences Questionnaire
    Racine N, Killam T, Madigan S. Trauma-Informed Care as a Universal Precaution: Beyond the Adverse Childhood Experiences Questionnaire. JAMA Pediatr. 2020;174(1):5–6. doi:10.1001/jamapediatrics.2019.3866 
  • On-the-Go Training: Downloadable Modules to Train Medical Students to Care for Adult Female Sexual Assault Survivors
    Siegel M, Gonzalez EC, Wijesekera O, et al. On-the-Go Training: Downloadable Modules to Train Medical Students to Care for Adult Female Sexual Assault Survivors. MedEdPORTAL. 2017;13:10656. Published 2017 Dec 11. doi:10.15766/mep_2374-8265.10656

Obtaining Consent and Understanding Victimization/Boundary Violation by Physicians

• Introduction

  Physicians are called to uphold the highest ethical standards as evidenced in every code of ethics including the AOA code of ethics. To develop and attain this standard, we must help medical students and trainees cultivate their own judgement about boundaries rather than preaching rule-orientation. This set of resources is designed as a starting point for such conversations and activities.

• What Is Consent and How Is It Obtained?

  1. Code of Ethics

  1. State the ethical obligations / boundaries for physician-patient and physician-prospective / prior patient relationships (including patient rights)
  2. Apply the code of physician ethics to complex / difficult clinical case scenarios

  2. Communication

  1. Describe a culture of consent in medical practice
  2. Demonstrate the ability to communicate in a way consistent with a culture of (explicit) consent
  3. Describe the difference(s) between consent and informed consent
     1. Identify when each is implemented

• Selected Resources

  • AOA Rules and Guidelines on Physicians’ Professional Conduct
  • AMA Informed Consent - Code of Medical Ethics: Consent, Communication & Decision Making
  • Consent Requirements for Pelvic Examinations Performed for Training Purposes
    Gibson E, Downie J. Consent requirements for pelvic examinations performed for training purposes. CMAJ. 2012;184(10):1159-1161. doi:10.1503/cmaj.110725
  • Consent for the Pelvic Examination Under Anesthesia by Medical Students
    Hammoud MM, Spector-Bagdady K, O'Reilly M, Major C, Baecher-Lind L. Consent for the Pelvic Examination Under Anesthesia by Medical Students: Recommendations by the Association of Professors of Gynecology and Obstetrics. Obstet Gynecol. 2019;134(6):1303-1307. doi:10.1097/AOG.0000000000003560 
  • Consent for Pelvic Examinations Under Anesthesia by Medical Students: Historical Arguments and Steps Forward
    Cundall HL, MacPhedran SE, Arora KS. Consent for Pelvic Examinations Under Anesthesia by Medical Students: Historical Arguments and Steps Forward. Obstet Gynecol. 2019 Dec;134(6):1298-1302. doi: 10.1097/AOG.0000000000003509. PMID: 31764742; PMCID: PMC6905127.

The Development of Core Professional Values

• Introduction

  The character strengths and values needed to enter the ethical and professional practice of medicine must be learned and/or reinforced across the educational continuum. Professional identity formation is the process of internalizing the core values, beliefs, and behaviors of medicine; however, few curricula focus on this aspect in an explicit way. This set of resources is a starting point for schools to identify extant elements for enhancement or to vision a path toward guiding professional identify formation of medical students and trainees.

• A. Professional Identity Formation

  A. Professional Identity Formation

  1. Identify stages of identify formation across the medical education continuum
  2. Describe various power differentials and the process of trust development
  3. Discuss the impact mentors and role models on physician (in-training) socialization
  4. Discuss the impact of clinical and non-clinical experiences on physician (in-training) socialization
  5. Reflect on the concept of communities of practice within healthcare

• B. Physician Contract with Society

  
  <ol style="margin-left: 40px;">
      <li>Describe the two roles of physician: professional and healer</li>
      <li>Identify society&rsquo;s expectations of a physician </li>
      <li>Discuss the impact of the hidden curriculum on development of core values</li>
      <li>Describe the impact of self-care on the ability to fulfill the societal contract</li>
  </ol>

• Selected Resources

  • Developing “a Way of Being”: Deliberate Approaches to Professional Identity Formation in Medical Education. Chandran L, Iuli RJ, Srano-Paul L, Post SG.
  • Professional Identity Formation in Medical Education: The Convergence of Multiple Domains
    Holden M, Buck E, Clark M, Szauter K, Trumble J. Professional identity formation in medical education: the convergence of multiple domains. HEC Forum. 2012 Dec;24(4):245-55. doi: 10.1007/s10730-012-9197-6. PMID: 23104548. 
  • Parting the Clouds: Three Professionalism Frameworks in Medical Education
    Irby DM, Hamstra SJ (2016) Parting the Clouds: Three Professionalism Frameworks in Medical Education, Academic Medicine  91(12) 1606-1611 doi: 10.1097/ACM.0000000000001190 
  • The Formation of Professional Identity in Medical Students: Considerations for Educators
    Goldie J (2012) The formation of professional identity in medical students: Considerations for educators, Medical Teacher, 34:9, e641-e648, DOI: 10.3109/0142159X.2012.687476
  • Professionalism and Medicine’s Social Contract with Society Virtual Mentor. 2004;6(4):185-188. doi: 10.1001/virtualmentor.2004.6.4.msoc1-0404
  • A Practical Framework for Remediating Unprofessional Behavior and for Developing Professionalism Competencies and a Professional Identity
    Barnhoorn PC, Houtlosser M, Ottenhoff-de Jonge MW, Essers GTMJ, Numans ME,  Kramer AWM (2019) A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity, Medical Teacher, 41:3, 303-308, DOI: 10.1080/0142159X.2018.1464133 
  • ABIM Foundation: What is Medical Professionalism?
  • Drexel Professional Formation 
  • Identity and Authenticity in Medical Ethics
    Charles Foster, TEDxHautLacSchool
  • Doctors in Distress: Saving the Lives of Those who Save Lives  
    Dr. Ed Ellison  TEDxNaperville
  • Physician Well-being and Professional Fulfillment
    American College of Physicians online