Shedding Light on the Hidden Curriculum: A Systematic Review of Ethics Education during General Surgery and Subspecialty Training

Abstract

Introduction: Ethics education in surgical residencies is often delivered in an informal and nonstructured manner as part of a "hidden curriculum", leading to few residencies routinely including it in their core curriculum. This systematic review aimed to summarize the delivery modes, curriculum, structure, and effectiveness of ethics educational interventions for surgical trainees.

Methods: We performed a comprehensive database search including MEDLINE, Embase, Scopus and CENTRAL to search for articles describing the implementation of ethics educational interventions for general surgery or subspecialty trainees.

Results: A total of 14 studies were included. Only 2 centers performed targeted needs assessment. Curricula covered included informed consent, the doctor-patient relationship, breaking bad news, decision-making, end-of-life care, conflicts of interest, considering patients' personal contexts, and surgical research ethics. Modes of delivery varied across studies, including case-based learning, group discussions, didactic lectures, reading material, role-playing, simulated patients, and ethics morbidity and mortality (M&M) meetings. Evaluations were most commonly via surveys exploring knowledge and self-reported confidence, with only 3 studies measuring actual trainee performance using objective structured clinical examinations. In general, the educational interventions increased trainees' confidence/preparedness in handling ethical dilemmas.

Conclusion: We recommend comprehensive local needs assessment to guide curricular development and designing specific learning objectives and measurable milestones to ensure evaluation. Educational interventions are best delivered in a graduated manner with the complexity of the topic mirroring residents' real-life clinical responsibilities and experiences. Teaching modalities should be tailored according to the nature of the curricular content being taught to make the learning experience more interactive and effective.

Keywords: Bioethics; Curriculum; Ethics; Residency; Surgery; Training.