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Michael J. Green, MD, MS; Gary Mitchell, MD; Carol B. Stocking, PhD; Christine K. Cassel, MD; Mark Siegler, MD

Arch Intern Med. 1996;156(3):298-304.

Abstract
Objective
To assess the extent to which actions reported by internal medicine trainees conflict with published guidelines on ethics.

Methods
A confidential survey was sent to a random sample (N=1000) of associate members of the American College of Physicians (ACP). Questions were asked about ethical decision making in areas addressed by the guidelines in the ACP Ethics Manual. Quoted manual guidelines were provided, followed by 55 yes or no questions, such that a yes answer represented an action that conflicted with a guideline. There were two follow-up mailings to nonresponders.

Results
Forty percent (n=397) completed the questionnaire; 17% indicated they were aware of the guidelines on ethics. On average, associates responded yes to 16% of questions where a yes response indicated they have acted outside guidelines on ethics one or more times. The mean number of responses (n=55) that conflicted with a guideline was 7.6 per person (SD, 4.7 responses; range, 0 to 33 responses). Ninety-eight percent of respondents reported actions falling outside a guideline one or more times and 80% did so four or more times. The most frequently reported reason (965/3219 [30%]) from a list of four choices for acting outside a guideline was "I was aware of the guideline, but this did not represent an ethical dilemma to me."

Conclusions
Few responding ACP associates indicated awareness of the ACP guidelines on ethics. Physicians in training nevertheless reported acting according to the presented guidelines most of the time, although nearly all respondents acted outside a guideline at least once, and some did so many times. Reported behaviors were sometimes inconsistent with consensus ethical standards that apply to internists. Physicians in training need to know more about ethical standards that apply to their own practice and should be aware when their actions deviate from ethical norms. Before acting outside guidelines on ethics, trainees should discuss their conflicts with others, such as attending physicians, clinical ethicists, or hospital ethics committees.

(Arch Intern Med. 1996;156:298-304)

Author Affiliations
From the MacLean Center for Clinical Medical Ethics (Drs Green, Mitchell, Stocking, and Siegler) and Department of Medicine (Dr Cassel), University of Chicago, Chicago, Ill. Dr Green is now with the University of Wisconsin Medical School, Madison; Dr Mitchell is now with Indiana University School of Medicine, Indianapolis; and Dr Cassel is now with Mount Sinai Medical Center, New York, NY.

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