Matthew Kenney, Ph.D., HEC-C
Curt Ward, MD, MBA, FAAFP

Introduction
As one of the largest Catholic healthcare systems in the United States, Ascension has 154 accredited Graduate Medical Education (GME) Residency programs with 66 specialties and subspecialties dispersed across 12 states. On average, we educate over 2,700 residents annually. Accordingly, Integration of ethics education into Graduate Medical Education Residency is recognized as an essential component of the ACGME Milestones leading to competency in Professionalism.¹ The delivery of high quality, standardized yet customizable, collaborative ethics education is a significant strategic priority for Ascension. In addition, the need to move to a virtual curriculum in the context of the COVID-19 pandemic created both challenges and opportunities for engaging in medical resident education as a high reliability endeavor, which leveraged the expertise of our Medical Residency Program faculty, our community of ethicists (called our Ethics Advisory Community) across our system, as well as the perspectives and experiences of our Medical Residents themselves.

Curriculum Overview
In partnership with the Directors of Residency Programs across Ascension, the Ethics Advisory Community designed and is in year two of a two-year, case-based methodology curriculum in ethics specifically designed to be delivered nationally using a virtual format. Specific residency programs rotate facilitation responsibilities with the support of and collaboration with their Ministry Market Ethics colleagues. Drawn from the ACGME Milestones, topics covered in the curriculum include: Do Not Resuscitate, Withdraw/Withhold of Medical Interventions, Competence and Decision Making Status, Inappropriate Demands for Medical Interventions, Informed Consent, Confidentiality and Privacy, Advance Directives, Physician Assisted Suicide, and Professionalism/Duty to Care. All presentations are encouraged to integrate ethical principles, the Ethical and Religious Directives for Catholic Healthcare Services (ERDs) and aspects of the case study/education related to cultural competency, diversity and inclusion.

Format
Each Medical Resident Ethics Grand Rounds is offered nationally to all Residency programs during their set Residency Grand Rounds structure on a quarterly basis such that the curriculum is completed over the course of a two-year cycle. The sessions are designed to be 60-minute didactics that include: a case study selected and presented by a Medical resident or residents from the hosting Ministry Market, with subsequent discussion co-facilitated by Director or Faculty of the Medical Residency Program and Ascension Market ethicists utilizing the Ascension Assess, Analyze, Act Clinical Ethics Decision-making Process relative to topic, and open Q&A, time allowing. The standard presentation will include:

1. Overview of Case Related to Designated Topic
2. Identification of the Central Ethics Question posed by the case
3. Applicable Ethical Principles, Policies, and The Ethical and Religious Directives relative to the topic
4. Familiarity for Residents in referencing the Ascension myEthicsRx App relative to the topic

A standardized yet customizable slide deck template is provided to assist hosting Ministry Markets in preparing their didactic sessions. Each module is recorded, and the video/supporting materials are made available to Program Directors for future use, and National Continuing Medical Education (CME) credit is available for both the live and recorded sessions.

Roll Out
As mentioned above, various Ministry Market GME programs within Ascension rotate "hosting" of Medical Resident Ethics Grand Rounds. Planning meetings are scheduled at least two months in advance of the Grand Rounds date to allow for selection of a relevant case and Medical Resident(s) to present the case study, and for the collaborative development of the presentation itself. Lead national faculty from Graduate Medical Education and Ethics support Market Program Directors, Designated Institutional Officers (DIOs), Residents and Ethicists in the planning and development of the presentation, and all Ascension Residents, faculty, program directors and ethicists are invited to attend.

Lessons Learned (So Far)

1. The physician voice is key: A crucial element in the success and dialogical nature of the Grand Rounds is to have the Residents and faculty lead the conversation and the ethicists to facilitate and provide support and subject matter expertise where needed. In short, ethicists are supposed to care about integrating ethics into all facets of the organization; when a Medical Resident peer speaks to her/his colleagues utilizing an ethics lens to examine a case with which they struggled or in which they found meaning, this is a powerful message. And, when Residents hear their faculty speak to the ethical dimensions of their vocation as a physician, this sends a very powerful message.
2. Standardize when necessary, but be flexible: As we began to gain some experience in delivering national virtual Grand Rounds, we found that there were a few key elements (those outlined above) which we would want to have included in any of our Ethics Grand Rounds presentations, both to meet the requirements laid out in the ACGME Milestones for Professionalism, and to also endeavor to establish a common way of approaching ethical dilemmas across our system using standardized tools and resources (like Assess, Analyze, Act and Ascension's myEthicsRx app). However, the most effective and engaging presentations thus far seemed to be those that left space for discussion, debate, and sometimes even going a bit "off script."
3. Don't let the perfect be the enemy of the good: As mentioned above, customarily, we begin the planning process for the Quarterly Grand Rounds immediately after the previous one finishes. This allows three months for planning and collaboration. However, sometimes it is difficult to coordinate schedules, select a relevant case, and have a draft presentation ready in time for a "dry run" a few days before the live presentation. And, even with all the elements of planning in place, sometimes technical difficulties inherent in a virtual delivery modality are unavoidable. These "imperfections," as long as they do not stall the whole presentation, are unavoidable, and may actually make the presentation more authentic.
4. Give them credit: Ascension's ability to coordinate Continuing Medical Education (CME) credit on a national level across all of our Ministry Markets through one centralized clearing house makes both the process for securing CME credits for the program and the participants' ability to receive credit for participation much more streamlined. It also allowed for us to advertise the program nationally and offer CME credits for those who participated in the live session or viewed the recorded program.
5. Include discussion of implicit/explicit bias if applicable: One key learning we had as we engaged in these presentations is that many of the cases presented had elements of cultural competence, implicit or explicit bias present in them in some form, and that recognizing and addressing these elements, if possible, contributed to a positive resolution to the case and significant learnings for those involved. Any opportunity to draw these elements out of cases, when they exist, helps to connect Residents to the mission of Catholic healthcare, and to the principles of inclusion, diversity and human dignity.
6. "If you build it, they will come": Word spread across our national ministry. After each Grand Rounds, more GME programs reached out to access the recordings and to offer to participate in future Grand Rounds. GME programs need assistance to deliver on all of the ACGME requirements and meet the needs and interests of the learners. This is a great example of the interprofessional teaming expected by the ACGME to deliver a highly reliable clinical learning environment.
7. Yes, it is still a pandemic: As mentioned above, the COVID-19 pandemic necessitated that we explore a new delivery modality for medical education, since many in-person avenues of education were suspended. This provided the impetus for the creation of this virtual curriculum. However, the pandemic has and continues to have a tremendous impact on our hospitals, healthcare systems, and communities, including our Medical Residents and the faculty who support them. For many, the Ethics curriculum has provided a strong reminder of why the vocation of the physician is so important, and why a moral compass, rooted in our identity as a healing ministry of the Church and guided by foundational social and ethical principles, is indispensable. Yet, we have had to recognize the strain our physician colleagues are under, and postpone or even cancel some scheduled sessions. Again, flexibility, and above all, compassion, is key. The Curriculum, and the work of ethics more broadly, is to support clinicians, not to impose additional burdens. Ideally, programs such as this can help ease moral distress, soothe compassion fatigue, and provide a forum in which ethicists and physicians can mutually support each other in the important work of healing.

Matthew Kenney, PhD, HEC-C
Vice President, Ethics Integration and Education
Ascension
Ivoryton, Connecticut
[email protected]

Curt Ward, MD, MBA, FAAFP
Lead Physician/Director of Internal Medicine
Ascension St. Vincent Hospital
Indianapolis, Indiana
[email protected]

ENDNOTE

1. https://www.acgme.org/globalassets/milestonesguidebook.pdf