Short communications

References
ASSOCIATION OF AMERICAN MEDICAL COLLEGES (1999) Contemporary Issues
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COLE, S. & BIRD, J. (2000) The Medical Interview, The Three Function
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HARGIE, O., DICKSON, D., BOOHAN, M. & HUGHES, K. (1998)
A survey of communication skills training in UK schools of

medicine: present practices and prospective proposals, Medical

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KURTZ, S., SILVERMAN, J. & DRAPER, J. (1998) Teaching and
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MAKOUL, G. (2001) Essential elements of communication in medical
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Medical Teacher, Vol. 28, No. 2, 2006, pp. 182184

Medical ethics and tomorrows physicians: an aspect

of coverage in the formal curriculum
KHALID UMRAN AL-UMRAN1, BASIL ABDULRAHMAN AL-SHAIKH2,
BASSAM HASSAN AL-AWARY3, ABDULLAH MOHAMMED AL-RUBAISH4 &
FAHD ABDULAZIZ AL-MUHANNA5
1
Professor in Paediatrics; 2Associate Professor in Physiology; 3Assistant Professor in
Paediatrics; 4Associate Professor in Internal Medicine; 5Professor in Internal Medicine,
College of Medicine, King Faisal University, Dammam, Kingdom of Saudi Arabia

ABSTRACT Medical ethics has created contentious issues and

requires reforms in medical education such as renewed emphasis
on formal instruction. The aim here was to review the current
status of bioethics teaching in medical schools, determine Saudi
students perception of its coverage in the formal curriculum and
make recommendations. Using a self-administered questionnaire
in a cross-sectional study, undergraduate students opinion about
medical ethics coverage was obtained. Fourteen clinical
departments and 201 students were studied. Only 46% of
respondents were satisfied with the current coverage of ethical
issues in the formal curriculum; 23% were unaware of the value
of the subject. Students approval rate was highest in Neurology
and Psychiatry (70%). The study confirmed inadequate
formal instruction on medical ethics in a developing country.
Five recommendations are made. At admission, students
integrity and character should be assessed. Bioethics should be
taught in clinical settings. In the Islamic world, medical
curricula should include the Islamic code of medical ethics.
Peers, nurses and patients should evaluate graduates performance in ethics at the bedside. Evidence-based assessment and
continuous quality improvement are required to maintain the
requisite standard.

(1987) stated that, in order to meet the current needs

of clinical practice, medical ethics must examine how its
focus, methods, style and research must at once reflect and
yet differ from its parent disciplines philosophy and
religious studies.
Medical ethics, a precursor of bioethics, dates back to
500 years BC. (Al-Mahroos & Bandaranayake, 2003). Veatch
(1989) traced it to the Hippocrates, and referred to the early
codes of Percival (1803) and Gregory (1817). The German
guidelines on human experimentation (1931) were the first
of its kind for therapeutic and scientific research on
humans, and, remained in force until 1945. Issued in 1947,
the Nuremberg code also contained guidelines on human
experimentation. Medical ethics in Islam was highlighted
in Adab al Tabib (The Ethics of Physicians), and,
writing about doctors code of ethics, Al-Ruhawi stated:
The virtuous physician can improve both body and soul
(Pellegrion, 1980).
With its primary focus on the doctor-patient relationship, traditional medical ethics has developed since the 1950s
into bioethics. In the last five decades, ethics topics for public
debate included definition of death, HIV/AIDS, animal
rights, cloning, stem cell research, fetal neural tissue
transplantation, the human genome project as well as

Introduction
Ethics defies a precise definition. The Webster New World
Dictionary defines it as relating to what is good or bad;
having to do with moral duty and obligation. Ackerman
182

Correspondence: Prof. Khalid Al-Umran MD, FRCPCH, PO 40140,

Al-Khobar, 31952, Saudi Arabia. Tel/fax: 00 9663 8594147;
email: khalid_umran@yahoo.com

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Short communications

cross-cultural medical ethics and alternative medicine.

Furthermore, concern about medical ethics has become
increasingly prevalent. Factors underlying this trend include
technologic advances in medicine (such as life-sustaining
treatments), human reproduction, organ donation, health
care teams, social interest in freedom and autonomy, and the
rising cost of health care delivery (Miles et al., 1989;
Steinberg, 1995).
Accordingly, there is a need to reform medical education
to address these concerns. Although ethics has always been
of fundamental importance to the medical profession,
different countries have differing opinions on its social
and religious basis. The World Health Organization
(WHO) has called for renewed emphasis on formal instruction in biomedical ethics (Walton, 1993).
Whereas most medical schools in western countries have
heeded this call (Steinberg, 1995), those in many developing
countries have not. Patenaude et al. (2003) reported a
disturbing trend from Bahrain which showed deterioration in
moral reasoning among medical students. And, Al-Shehri
(2001) found lack of education in medical ethics in most
medical colleges in Saudi Arabia.

Purpose, methods and results

The purpose of this study was to determine Saudi medical
students perception of medical ethics coverage in the
formal curriculum, compare the findings with current status
of bioethics teaching in developing countries, and make
recommendations.
A cross-sectional study was conducted in the College of
Medicine, King Faisal University Dammam, Saudi Arabia.
A self-administered questionnaire was used to obtain
students opinion on whether medical ethics was adequately covered. The target population was all clinical
undergraduates in the 20032004 academic year. The
actual sample was all students who attended clinical classes
on the study days. The students received no prior warning
of the study. Questionnaires were distributed in the
classrooms, completed by students at their own pace
without prompting, and retrieved at the same sitting.
Clinical sub-specialties were excluded because, for the
purposes of the study, the two parent departments,
Internal Medicine and Surgery, were considered sufficiently
representative.
Fourteen clinical departments and 201 students were
studied. Table 1 shows the distribution of their responses.
The current coverage of ethical issues in the curriculum was
found satisfactory by 46% of respondents, deficient by 31%,
and, 23% were not even aware of the value of the subject.
Whereas 71% considered coverage adequate in neurology
and psychiatry courses, only 38% thought it was in Internal
Medicine courses.

Discussion and recommendations

In addition to the WHO, Gillon (1985) suggested that
there should be formal education in medical ethics to ensure
that physicians conscience, good character and integrity
would develop appropriately during medical school. Medical

Table 1. Students response on coverage of ethical issues

in the named courses (n 201).

Department
Anesthesiology
Dermatology
ENT
FAMCO
Forensic Medicine
Internal Medicine
Neurology
Obstetrics/Gynecology
Ophthalmology
Pediatrics
Pharmacology
Psychiatry
Radiology
Surgery
Total

Properly
covered (%)
135
107
111
129
125
76
143
56
24
141
82
143
66
76
93

(67)
(53)
(55)
(64)
(62)
(38)
(71)
(28)
(12)
(70)
(41)
(71)
(33)
(38)
(46)

Not properly
covered (%)

Not sure
(%)

0 (0)
76 (38)
22 (11)
30 (15)
46 (23)
93 (46)
58 (29)
72 (36)
89 (44)
20 (10)
82 (41)
42 (21)
66 (33)
48 (24)
62 (31)

66 (33)
18 (9)
68 (34)
42 (21)
30 (15)
32 (16)
0 (0)
72 (36)
89 (44)
40 (20)
36 (18)
16 (8)
68 (34)
76 (38)
46 (23)

educators of tomorrows doctors face the problem of what,

how, when and where to teach bioethics. The focus used to be
on the patientphysician relationship especially truthfulness,
(veracity), informed consent, fidelity, confidentiality and
non-malfeasance (Miles et al., 1989). However, if bioethics
is to be taught adequately, topics which also must receive
attention include philosophy, human behavioral and social
sciences, as well as the humanities, liberal arts and the moral
and legal foundations of medicine (Ackerman, 1987; Miles
et al., 1989).
The WHO (Walton, 1993) and the American Medical
Association believe in formal integration of medical ethics
into the curriculum. In practice, medical ethics is taught
as part of forensic medicine in India, Sri Lanka and most
Arab countries (El-Marti, 1995), but, as an independent
course in only a few (e.g. Basra University; Yacoub & Ajeel,
2000). In the Arabian Gulf University, Bahrain, it is taught
only premedical as part of Islamic Studies (Al-Mahroos &
Bandaranayake, 2003). However, in subsequent years, there
are neither systematic courses nor structured integration into
the curriculum, except for a vertically integrated preclinical
course in communication skills, which combines cognitive
and practical skills.
The following recommendations are made. In order to
strengthen the role of ethics in medical education, medical
educators should adopt more than one strategy. First, at
admission, students should be assessed for integrity and
character. Secondly, bioethics should be taught in clinical
settings during medical school and residency training.
Thirdly, in the Islamic world, medical school curricula
should contain a study of Islamic code of medical
ethics. Fourthly, peers, nurses and patients should evaluate
graduates performance in ethics (Singer, 2003). Finally,
although some of these strategies are already being adopted
in some medical schools, evidence-based assessment
combined with continuous quality improvement measures
are required to ensure that the requisite standards are
being maintained.
183

Short communications

Acknowledgements
We thank our students for answering the questionnaire,
Prof. Lade Wosornu for editorial suggestions and
Mr. Jessie Asilo for technical assistance.

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Notes on Contributors
Prof. KHALID UMRAN AL-UMRAN, MD, Arab Board, FRCPCH (UK),
Professor in Pediatrics & Vice Dean, Clinical Affairs, King Faisal
University, College of Medicine, KSA.
Dr. BASIL ABDULRAHMAN AL-SHAIKH, PhD (Sheffield University, UK),
Professor in Physiology and Dean, College of Medical Laboratory
Technology, King Faisal University, College of Medicine, KSA.
Dr. BASSAM HASSAN AL-AWARY, MD, KFU Fellowship (KSA), Assistant
Professor in Pediatrics and Vice Dean Hospital Affairs, King Faisal
University, College of Medicine, KSA.
Dr. ABDULLAH MOHAMMED AL-RUBAISH, MD, Arab Board, Associate
Professor in Internal Medicine and Dean, College of Medicine, King
Faisal University, College of Medicine, KSA.
Prof. FAHD ABDULAZIZ AL-MUHANNA, MD, Arab Board, KFU Fellowship
(KSA), Professor in Internal Medicine, King Faisal University, College of
Medicine, KSA.

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AL-MAHROOS, F. & BANDARANAYAKE, R.C. (2003) Teaching medical

ethics in medical schools, Annals of Saudi Medicine, 23, pp. 15.
AL-SHEHRI, M.Y. (2001) Medical curriculum in Saudi Medical
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EL-MARTI, A. (1995) The teaching of medical ethics in Arab countries:
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GILLON, R. (1985) Conscience, good character, integrity and to hell
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VEATCH, R.M. (1989) Medical Ethics (Boston, Jones and Bartlett
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Medical Teacher, Vol. 28, No. 2, 2006, pp. 184186

A sexual history-taking curriculum for second year

medical students
ELLEN WAGNER1, GARY MCCORD1, LUANNE STOCKTON1, VALERIE J. GILCHRIST1,
DINAH FEDYNA1, LISA SCHROEDER2 & SANDEEP SHETH3
1
Northeastern Ohio Universities College of Medicine (NEOUCOM), OH, USA;
2
Barberton Citizens Hospital, Barberton, OH, USA; 3Akron General Medical Center, Akron,
OH, USA

ABSTRACT The purpose of this study is to describe the evaluation of a sexual history-taking curriculum and correlates of
student performance during a Clinical Skills Assessment. Reading
assignments, small group discussions, a Saturday Sex workshop
and performance on a Clinical Skills Assessment were evaluated.
Students most favorably rated the workshop and least favorably
rated the reading assignments. Eighty-four percent of students
asked at least one sexual history question on the Clinical Skills
Assessment. We were unable to identify any independent predictors
of sexual history-taking behavior.

184

Introduction
Physicians underestimate the prevalence of patients sexual
concerns (Nusbaum & Hamilton, 2002) and often do not
ask sexual history questions (Mathews & Linn, 1989), even

Correspondence: Ellen Wagner, MS, Northeastern Ohio Universities College

of Medicine (NEOUCOM), Department of Family Medicine, 4209 State
Route 44, PO Box 95, Rootstown, OH 44272, USA. Tel: 330-325-6777;
fax: 330-325-5903; email: ewagner@neoucom.edu