Evaluation, both of teaching programs themselves and of individual students, is still in flux. Most formal courses have included a pass—fail grading system based on class participation and written exercises, usually either papers or in-class essay examinations. These efforts convey to students the importance of medical ethics in the medical school (as has the addition of questions to the national boards and many of the specialty boards).

Efforts to develop formal and valid evaluation techniques have remained hampered, however, by uncertainty about what specific teaching goals are most important, about how best to measure whether any of those goals have in fact been accomplished, and about what is realistic to expect from ethics courses. (Similar constraints plague efforts to teach professionalism [Arnold].) Underlying the challenge of evaluating the impact of teaching medical ethics is a deeper debate regarding what teaching ethics does. Ethics as an academic discipline can be taught; one can evaluate a student's knowledge of ethical concepts and cognitive skills. Philosophers in undergraduate ethics courses have done this for centuries. Most attempts at evaluation in medical school have tried to measure this aspect of the ethics curriculum using essay or short-answer tests.

In arguing for the importance of formal ethics education, teachers of medical ethics typically have emphasized more ambitious goals, such as improving students' ability to address ethical issues in clinical practice or promoting humanistic qualities such as integrity. Efforts at evaluation, however, have not always distinguished among residents' attitudes, knowledge, or behavior. Moreover, there are numerous methodological problems, particularly in evaluating ethical behavior or character, problems that are compounded if one tries to determine whether improvements are attributable to formal ethics teaching. Some faculty involved in ethics programs question whether stricter standards of evaluation should be required of their curricula, arguing that courses in the traditional areas of anatomy, biochemistry, and physiology have rarely, if ever, been required to prove their ultimate effectiveness.

Attempts to develop innovative methods of evaluation have included measuring students' moral reasoning, evaluating students' behavior by nonphysicians (such as nurses or patients), and using formal tools such as the Objective Standardized Clinical Examination. These exercises have attempted to move beyond merely evaluating cognitive skills to analyzing students' actual behavior. Although these efforts show a great deal of promise as formative educational tools, few schools use these tools as summative evaluation methods. Limitations in their psychometric properties and the large number of raters needed for reliable ratings have limited their general use.

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Anxiety and Depression 101

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