Ethics Education and Training Among Obstetrics and Gynecologists in Iran: A Cross-Sectional Study

Abstract

Background: Prime ethical values are essentially characterized by family and social principles as well as the skills and knowledge acquired through training and education, but such principles alone potentially miss the understanding of ethical predicaments that medical professionals encounter in their medical practice. This study aimed at evaluating the situation of medical ethics education and training as acquired in gynecology and obstetrics professions in Iran as well as Middle East.

Method: A cross-sectional survey was conducted on working-class obstetricians and gynecologists in Iran from the January 2013 to January 2014. A close ended monkey survey questionnaire was used to gather data from the targeted population. Cochran formula was used to determine a sample size of 386 population groups. Correlation between formal and informal variables as independent variable, and age, position, board certification, and gender were tested by using Chi-Square statistical distribution. The outcome of the study was reported in terms of odd ratios, P-values, 95% confidence interval, and a standard error. All statistical analysis were performed by using version 9.2 version of the SAS software except determination of the sample size which was done by using N-Query Advisor Version 4.0.

Results: With a response rate of 39.1%, 26.4 % of the participants were both informally and formally trained in medical ethics while 23.0 % were formally educated and trained in medical ethics. 24.2 % of the participants were totally not educated or trained in medical ethics. Further analysis of the relationship between the variables indicted that gender or sex, board, and position of the participants in their work place were not significantly associated with medical ethics and bioethics education. It was also found that in spite of having insignificant association with bioethics education, the age variable revealed that young obstetricians and gynecologist of age 30 years and below as well as the group whose age fall between 31 to 49 years were formally, and informally educated and trained in bioethics. The participants whose ages were 50 years and above had minimal education and training in bioethics and medical ethics.

Conclusion: The study concluded that even though Iran has experienced improvement in the sector of medical ethics in different aspects, but the effectiveness and the quality of the medical education offered in Iranian medical colleges and universities is still low.

Keywords: Obstetrics and Gynecology, Ethics Education, Ethics Training, Iran.

Introduction

 Familial and societal principles, in addition to knowledge and skills gained through education and training, is an integral part of optimal ethical values. However, family values and societal principles alone lack in procuring an efficient insight into ethical dilemmas encountered by medical professionals in their medical practice.  Currently, ethics teaching and training have gained momentum. Ethics education has also rapidly expanded in residency programs in several specialties (e.g., internal medicine, pediatrics, family medicine, and psychiatry).1 In addition, ethical medical, educational training is incorporated into different residency training programs worldwide, including programs for obstetrics and gynecologists. The Royal College of Obstetricians and Gynecologists (RCOG), the American College of Obstetrics and Gynecology (ACOG), and (FIGO) which has 125 national member societies of gynecologists and obstetricians from all over the world, organize these training programs.2,3                                                                                                      

However, current literature demonstrates inadequate formal ethics education and training in obstetrics and gynecology residency programs in Iran .4 The didactic learnings of  Iran obstetricians and gynecologists board training programs lack any components related to ethics, besides a brief reference to the importance of professionalism and communication skills.5 The recommendation of World Medical Assembly in 2015 to incorporate ethics education at all levels of medical education and training programs prompted Iran n obstetricians and gynecologists board training programs in early 2016 to update information regarding ethics education in all subspecialties for reference.6  This research is one of the few types of research evaluating the current situation of medical ethics education and training in Obstetric and Gynecologic specialty in The Middle East.

Methods

A cross-sectional survey of working obstetricians and gynecologists in Iran was conducted from January 2013 to 2014. Our study included all working levels of doctors (the residents, registrars and consultants) from various hospitals throughout the Country of Iran. The Monkey survey questionnaire were used and included questions to explore the methods of ethics education, and at which stage, beside characteristics. The optimal sample size for estimating proportions was 386 cohorts and determined by using the Cochran formula, by using N-Query Advisor Version 4.0. Test-retest reliability was ensured in a pilot study of 5 subjects prior to data collection. A random cluster sampling technique was incorporated for respondents in the study.

Bioethics education and training were assessed through 3 statements, about if they received education in medical ethics, which type, and where, Answers required single responses, such as ‘True,’ ‘False’ or ‘I do not know.’ Official ethical approval was obtained from the ethics committee at King Abdulaziz Medical City prior to the conduction of the study. The respondents were consented, and confidentiality and privacy were respected. Results were reported in terms of the odds ratio, standard error, 95% confidence interval, and P-value. Significance was accepted at α less than 0.05. SAS 9.2 was used for all statistical analyses.

Results

Descriptions of the characteristics of the respondents (Refer appendix)

A total of 391 out of 1,000 OB/GYN practitioners responded to the survey questions by email; therefore, the response rate was 39.1%. Participants responded from all provinces of Iran. Female responders totaled 257 (66.4%), which was almost double the rate of male responders. The married respondents totaled 291 (75.6%), whereas 60 (15.6 %) respondents were unmarried.

The study included participants of all ages, with approximate percentages of the participants below 30 years and above 50 years of age 71 (18.1%) and 72 (18.3%), respectively. There was an increase in participants of 31-49 years age group totaling 244 (63.1%); the participants’ ages 30-39 (140) 36.2%, while the ages of the other participants were 40-49 (104) 26.9%.Seventy-five percent of the participants were OB/GYN Board certificated, under different types of boards. Most of the physicians had Iran n board (18.7%) followed by Egyptian board (7%); however, physicians holding Western certificates from Canadian, RCOG, US or Indian boards were minimal in numbers.

The consultants and registrars in the sample numbers were 119 (34.4%) and 126 (36.4%), respectively; the remaining were being residents.

Table 1. OB/GYN Physicians’ characteristics

OB/GYN Physicians’ characteristics Characteristics N %
Gender Male 130 33.6
Female 257 66.4
Age (years) < 30                      71 18.3
30-39     140 36.2
40-49     104 26.9
≥ 50                      72 18.6
Position Resident               101 29.2
Registrar/specialist 126 36.4
Consultant 119 34.4
Board Certificate Europe board 41 10.5
Iran n board 71 18.2
Egyptian (Masters, Ph.D.) 27 6.9
Jordanian board 11 2.8
Canadian board 5 1.3
MRCOG 17 4.3
ABOG 6 1.5
Other 39 10.0

Bioethics education and training

Approximately 85 (26.4%) of the participants received mixed ethics education (formal ethics education and informal bioethics education), whereas 74 (23.0%) received only formal ethics education and 85 (26.4%) received informal ethics education. In addition, 78 (25%) did not have any type of bioethics education.

Approximately 75% of the responders received different types of formal and informal bioethics education. Of the responders, 25% had no bioethics education; 137(35%) of physicians received a formal education during medical school; however, only 46 (11.8%) throughout residency programs. Self-learning was the method used for informal bioethics education in 124 (31.7%) cohorts (see Table 2).

Table 2. Bioethics education and training

  Type of education N %
Did you receive teaching in bio-medical ethics? Formal education 74 23.0
Informal education            85 26.4
Both       85 26.4
No education 78 24.2

Table 3. Types of bioethics education and training

Type of bioethics education N %
Formal education In medical school 137 35.0%
During residency programs 46 11.8%
During sub-specialty programs 17 4.3%
In postgraduate programs 29 7.4%
Informal education In conferences 74 18.9%
Online training 50 12.8%
In courses and workshops 52 13.3%
Daily practice (grand round, case presentation, and commit.) 81 20.7%
Self-learning 124 31.7%

Bioethics education

No differences related to gender or the type of ethics education received in medical school during residency programs, postgraduate programs, conferences, courses and workshops, and daily practice were detected. However, male responders, more so than female responders, agreed to have received ethics education in sub-specialty programs. The same finding was true regarding self-learning and online training. Regarding marital status and type of ethics education, no significant differences during residency programs, sub-specialty programs, postgraduate programs, in conferences, in courses and workshops were found.

Regarding age,no significant differences were found in ethics education; except in medical schools. Responders under 30 years of age showed higher results (57.9%) followed by people between 30-39 years old (37.1%), and people aged between 40-49 years (28.8%). Participants > 50 years of age received minimum ethics education at medical school (19.4%). No significant statistical difference in relation to the type of board certificate and bioethics education was found, but it is noteworthy that Iran n board physicians learning from daily practice had a significant statistical difference from others (P< 0.010). In general, there was no significant statistical difference in relation to position or the type of ethics education, except that residents showed the highest agreement in relation to education in medical school, followed by registrar/specialists and then consultants.

Table 4: Distribution of ethics education according to characteristics

    Formal bioethics education Informal bioethics education
    medical school residency programs Sub-specialty postgraduate conferences Online courses& workshops Daily practice Self-learning
Sex Male 37.7% 2.3% 9.2% 8.5% 20.0% 18.5% 15.4% 24.6% 38.5%
Female 34.2% 1.7% 1.9% 6.6% 18.7% 10.1% 11.7% 19.1% 28.8%
Pearson Chi-Square -P .503 .855 .001 .508 .755 .021 .304 .205 .054
Age <30 57.7% 14.1% 0.0% 1.4% 21.1% 18.3% 8.5% 14.1% 33.8%
30-39 37.1% 13.6% 2.9% 7.9% 20.0% 10.0% 10.7% 20.0% 34.3%
40-49 28.8% 12.5% 8.7% 6.7% 16.3% 13.5% 17.3% 24.0% 31.7%
=> 50 19.4% 5.6% 5.6% 12.5% 19.4% 12.5 18.1% 23.6% 26.4%
Pearson Chi-Square -P .000 .321 .032 .083 .855 .402 .167 .389 .685
Board Europe 26.8 9.8 7.3 7.3 19.5 17.1 12.2 7.3 36.6
Iran 36.6 9.9 8.5 4.2 23.9 19.7 9.9 25.4 36.6
Egyptian 44.4 11.1 7.4 18.5 25.9 25.9 25.9 44.4 37.0
Jordanian 27.3 18.2 0.0 0.0 18.2 9.1 9.1 9.1 27.3
Canadian 20.0 20.0 0.0 20.0 0.0 20.0 40.0 60.0 40.0
MRCOG 23.5 17.6 5.9 0.0 29.4 23.5 11.8 35.3 47.1
ABOG 66.7 33.3 16.7 0.0 50.0 50.0 0.0 33.3 50.0
Others 28.2 12.8 2.6 17.9 7.7 2.6 28.2 23.1 25.6
Pearson Chi-Square -P .387 .759 .815 .064 .177 .029 .084 .010 .818
Position Resident 60.4% 17.8% 0.0% 4.0% 23.8% 11.9% 10.9% 18.8% 40.6%
Registrar/specialist 36.5% 13.5% 1.6% 11.1% 19.0% 12.7% 16.7% 27.0% 28.6%
Consultant 24.4% 9.2% 12.6% 8.4% 21.8% 18.5% 16.8% 22.7% 39.5%
Pearson Chi-Square -P .000 .174 .000 .144 .682 .298 .384 .346 .101

Discussions

Interpretation of the results

The results of this study showed that a significant percentage of the participants in the study had at least a form of medical ethics training and education. However, a considerable number of the participants in the study were completely not trained and were uneducated in medical ethics. In the study, the form of medical ethics training and education were classified into two types which included formal and informal education whereby formal medical ethics education and training is a category of medical ethics education obtained from institutional set ups such as medical schools, and in universities while informal medical ethics education and training is a category of medical ethics education obtained from relevant conferences, self-learning, workshops, online training, as well as through everyday practice. A significant segment of the participants who are trained and educated in medical ethics were formally trained and educated while another significant portion of the same cohort of the participants were informally trained. However, a substantial percentage of the same cohort of participant were both formally and informally trained. Moreover, it is important to note that the number of participants who were informally educated and trained in medical ethics significantly exceeded the number of the participants who were formally trained and educated in medical ethics. Most of the participants who received formal education and training in medical ethics and bioethics accomplished it in medical schools while a significant number learned medical ethics during their residency programs. On the other hand, self-learning is the form of informal education that most of the informally educated participants adopted in learning medical ethics. Nevertheless, a significant number of the participants who were educated informally in medical ethics adopted daily practice in learning medical ethics.

Four variables were statistically tested for their correlation with acquirement of ethics and bioethics education both formally and informally, and these included gender, age, and occupation of the participants as well as the type of board certification. Based on the results, it was found that gender is not associated or correlated with the means of acquisition of both formal and informal bioethics education except on sub-specialty and self-learning component of the formal and informal bioethics education respectively. It was realized that male participants received ethics education from sub-specialty program, self-learning, and online training than the female participants. The marital status variable was found to have no association with any component of formal and informal bioethics education acquisition. In regard to the age variable, it was found that most of the participants particularly whose ages were 30 years and below, acquired medical ethics education in medical schools followed by the participants of 30-39 years, and 40-49 years old. Not so many of the participants of ages 50 years and above received medical ethics education in medical school as well as from other avenue.  While the age variable had a positive correlation with acquisition of formal medical ethics education particularly in the medical school, it had zero association with the other components of formal and informal education.

With concerns to board certification, it was found that there is no relationship between acquisition of bioethics education, and board certification. In other words, the type of board certification that the participants had did not determine whether the participant was trained and educated in medical ethics and bioethics. The last variable tested in this study was the positions of the participants in their respective hospitals across Iran where they work as obstetricians and gynecologist specialist. The participants who took part in this study included individuals who work in the residents division, registrar division, and a as consultant in their respective hospitals across Iran. The analysis indicated that although acquisition of medical ethics and bioethics education is not associated with the positions occupied by the participants in their respective stations of work, but a significant number of the participants who work in the residents division of their respective hospitals were trained and educated in medical ethics and bioethics, and they received this training in medical school. However, some of the participants who work in the registrar and consultations sections of their respective work places were also trained and educated in medical ethics and bioethics from medical school.

Discussion of the result

The inclination to acquire medical ethics educations not only among the obstetricians and gynecologists, but the entire medical community in Iran is entrenched in Iran’s traditions, and Islamic culture(1). Historically, medical ethics was part of the Iranian traditional medicine curriculum used by medicine students in the benighted times, and renowned Iranian medical personalities are factually remarked for their extraordinary attention they paid to medical ethics in their teachings, practices, and publications(2). The introduction of the modern medical education in Iran in the early twentieth century came with medical ethics education as an important section of the courses that students were required to undertake(2). Courses associated with Medical ethics education were significant parts of the faculty of Medicine in Tehran University which was founded in 1934(1). The early books that were published on medical ethics after the introduction of modern ethics education in the Islamic Republic of Iran such as a book titled Medical Ethics and Customs by Dr. Etemadian comprehensively discussed the basic concepts of medical ethics such as confidentiality between a doctor and a patient, abortion, and euthanasia(1). Over the last two decade, the number of lectures on medical ethics education in different colleges of medicines as well as in universities across Iran have increased significantly(3).

Numerous books and journal articles on different aspects of medical ethics have been published, printed, and made part of the medical ethics curriculum in different medical courses including gynecology and obstetrics courses in Iranian medical colleges, and universities(3)(2)(3).  Additionally, Iranian medical colleges as well as universities have over the years implemented training techniques that centrally ensures that students undertaking medical courses including those are training to become obstetricians and gynecologists are not only trained, but receive quality education on medical ethics(4). An instance of such techniques is the use of case study or problem-case studies in teaching medical ethics which was introduced in year 2005 as part of the medical ethics curriculum(5). This elucidates on the statistical aspect of the outcome of this study particularly which indicates that a large section of the participants specifically of 30 years and below, and between 31 and 49 years of age had received medical ethics education from medical school. These cohorts of the participants essentially attained their education in obstetrics, and gynecology possibly in less than two decades ago either in Iran or other Middle Eastern countries as well as in Europe, and in this period of time, medical ethics education in Iranian’s medical colleges, and universities, and in other Middle Eastern countries such as Jordan had long been established, and had been significant section of the medical courses curriculum, including obstetrics and gynecology courses.

In addition to the aspect of development and advancement of the availability, teaching, and training of the modern medical ethics education in Iranian’s colleges, and universities over the past decades, principles of Islamic ethics can be attributed to the self-learning and practice of medical ethics by the Iran’s obstetricians and gynecologists as revealed in the study results(1). In Iran, discussions concerning ethical issues especially in the public outlets such as in the media are often done by legal personalities, physicians, and religious experts and scholar which is a clearly indication that matters concerning the principles of ethics and bioethics are embedded within the Islamic legal boundaries(6). In fact, solutions to ethics associated issues are often generated based on the Islamic lawful edicts(7). The Islamic culture practiced and followed by Iranians significantly stresses on unselfishness, and compassion as well as kindness to fellow human beings. Islamic teachings are observed by scholars of not only medical ethics, but ethics from a general stance, to be centered on perfecting the ethical conduct of human beings(2). Scholars, especially Islamic scholars and researchers on ethics consider the expedition for God in Islam to intensely involve moral and spiritual perfection, and the road to attaining such perfections entails practices that improves ethical behaviors of individuals including in their areas of work(1). The four values of medical ethics which include self-sufficiency, generosity, justice, and non-malfeasance as well as other related values like being kind and willing to help a another human being are principles that are accepted and intensely practiced in Islamic ethics(8). This explains finding of this study which revealed that a significant number of the participants received ethics and bioethics education through self-learning, and everyday practice. Adherence to the Islamic faith and principles is a significant factor that helped these participants to practice the principles of medical ethics in their places of work.

One of the findings of this study reveals that obstetricians and gynecologists working in the resident section of hospitals across Iran are well trained and educated in medical ethics.  This outcome is consistent with the outcome of a previous study conducted on the attitude of medical professionals working in the residents sections of hospitals across Iran, and other Middle Eastern Countries(9). In the functioning of any hospital in the world, residency programs normally requires utmost levels of ethical conduct among medical professionals including OB/GYN working in such programs(10). This is because residency programs centrally involves communication with patients, and it is the phase of any hospital where patients come in contact or communicate with a medical professional(9). Based on a study by Yousefzade et al. 2017, obstetrics and gynecology practices largely involves communication and conversation between patients and doctors, and the quality of a service given by obstetricians and gynecologists is largely measured by the level of ethical conducts a doctor have towards a patient(11). While on duty, obstetricians and gynecologists have the potential to learn and improve their ethical capabilities with time, and as they attend to different patients with different needs(12). While this is the situation in Iran for some obstetricians and gynecologists particularly the cohort that never formal medical ethics education and have to practice daily as well as learn by themselves, a number of recent studies highlights that the quality of the current medical ethics curriculum adopted by most medical colleges in Iran is adversative in different aspects which include its content, objectives, instructional materials, learning activities, and learning strategies(4)(5)(11)(13).

Although it would be anticipated that one of the requirements to be certified by any type of board as qualified obstetricians or gynecologists is acquirement of formal medical ethics or bioethics education, but based on the study findings of this research, obstetricians and gynecologists board certification not only in Iran, but also in Europe as well as in other Middle-Eastern countries pays negligible attention to the ethical capacities of the candidates that they certify to become obstetricians and gynecologists. Mohammadi and Allami highlights that uncertified scholars mostly focus their attention on areas that are often assessed by boards in order to prepare adequately for the certification processes, but fails or pay little attention to areas that are not often assessed by the board such as medical ethics education(9).

Based on the statistical aspect of the outcome of this study, a large portion of the participants who are uneducated and untrained in medical ethics were individuals of age 50 years and above. However, a few of this cohort of the participants were minimally educated in bioethics. While this is an area that have been overlooked by the prior scholars, the possible explanation of this phenomena is manifested in Iran’s plodding development in the sector of bioethics education over the past decades especially in the 20th century.  Iran’s track record in development of bioethics and medical ethics education have been gradual with one establishment lasting a significant number of years before another establishment is initiated(3). Moreover, developments concerning medical ethics education have been mainly at the national level whereby policies and regulations regarding publications and research in medical ethics were enacted, but the fundamental areas where the developments should been focused especially in colleges and universities were significantly overlooked until in the early 2000s(2). As such, the possibility that individuals who were in medical colleges and universities in the 1970s, through to 1980s and 1990s including obstetricians and gynecologists received medical education and training with minimal emphasis on medical ethics and bioethics is high. The commitment of Iran’s government towards development of medical ethics education mainly began in the early 1990s, and was observed by the first global conference medical ethics which occurred in Tehran in 1993, and was organized by the government of Iran through its Ministry of Health, and Medical Education(2).

Conclusion

 Most of the participants in this study are educated and trained in bioethics which is an indication that most obstetricians and gynecologists working in hospitals across different Iran’s provinces are trained and educated in medical ethics. While some of them have been trained and educated formally in medical colleges, others have informally been educated and trained especially through self-learning and practicing. However, based on the finding of this study, most obstetricians and gynecologists in Iran have acquired medical ethics education and training informally. Youthful Iranian obstetricians and gynecologists especially of age 30 years and below have acquired medical ethics education formally while obstetricians and gynecologists whose ages falls between 31 and 49 years have formally and informally acquired medical ethics education particularly in medical colleges and by daily practice respectively. In Iran as well as in other Middle-Eastern countries, board certification of scholars to become obstetricians and gynecologists pays minimal attention to medical ethics capability of the candidates undergoing through the certification processes to become certified obstetricians and gynecologists.

 Although Iran has improved in regards to developments associated with medical ethics education in such as introduction of legislations guiding physicians, obstetricians, gynecologists, and many other medical professions on what is expected of them in terms of ethical conducts, and also introduction of legislations that guides development of medical ethics curriculum to be used in medical colleges and universities, but there is still a concern among scholars on the effectiveness of the medical ethics and bioethics curriculum in practice.

References

1.        Larijani B, Zahedi F, Malek-Afzali H. Medical ethics in the Islamic Republic of Iran. East Mediterr Heal J. 2005;11(5–6):1061–72.

2.        Rispler-Chaim V. Islamic medical ethics in the 20th century. J Med Ethics. 1989;15(4):203–8.

3.        Zahedi F, Razavi SHE, Larijani B. A two-decade review of medical ethics in Iran. Iran J Public Health. 2009;38(SUPPL. 1):40–6.

4.        Bijani M, Ghodsbin F, Fard SJ, Shirazi F, Sharif F, Tehranineshat B. Journal of Medical Ethics and History of Medicine Original Article An evaluation of adherence to ethical codes among nurses and nursing students. :4–11.

5.        Bazrafcan L, Nabeiei P, Shokrpour N, Moadab N. Medical ethics as practiced by students, nurses and faculty members in Shiraz University of Medical Sciences. J Adv Med Educ Prof J Adv Med Educ Prof Abstr Orig Artic J Adv Med Educ Prof. 2015;3(33):33–8.

6.        Hajibabaee F, Joolaee S, Cheraghi MA, Salari P, Rodney P. Hospital/clinical ethics committees’ notion: An overview. J Med Ethics Hist Med. 2016;9:1–9.

7.        Enjoo SA, Amini M, Tabei SZ, Mahbudi A, Kavosi Z, Saber M. The main indicators for iranian hospital ethical accreditation. J Adv Med Educ Prof. 2015;3(3):117–32.

8.        Soltanian M, Molazem Z, Mohammadi E, Sharif F, Rakhshan M. Professional responsibility: An ethical concept extracted from practices of Iranian nurses during drug administration. Int J Pharm Res. 2018;10(3):346–53.

9.        Mohammadi N, Rahban H, Allami A. Medical Residents’ Attitude toward Professionalism and Assessment of Their Professional Behaviors: A Cross-Sectional Survey. Res Dev Med Educ. 2018;7(1):43–51.

10.      Brian-D. Adinma JI. Bioethics in Obstetrics. From Preconception to Postpartum. 2012;(2001).

11.      Yousefzadeh S, Zohani M, Mazlom SR, Feyzabadi MG. Knowledge and Attitude of Midwifery Students towards Observing the Ethical and Legal Standards of Patients ’ Rights. 2017;(4).

12.      Roudbari M, Yaghmaei M. The interns’ learning assessment in obstetrics and gynecology department of Zahedan university of medical sciences. Taiwan J Obstet Gynecol. 2007;46(3):248–54.

13.      Shidfar F, Sadeghi S, Kaviani A. A Survey of Medical Ethics Education in Iran Medical Faculties A Survey of Medical Ethics Education in Iran Medical Faculties. 2014;(January 2007).

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