Texas Medical Center

Book Offers ‘Novel’ Approach to Teaching Medical Ethics

In classes at The University of Texas Health Science Center at Houston, actors with
ethical dilemmas interact with first-year students who ask questions, explore ethical
issues and seek opinions.


By Meredith Raine  |  The University of Texas Health Science Center at Houston

As new students settled into classes this fall at The University of Texas Health Science Center at Houston, among the first educators they met were Wayne, Gloria and Sheila Brewster.

The Brewsters may be unexpected champions for ethics and professionalism in health care. Wayne is a hypochondriac with a drinking problem. His wife, Sheila, is having an affair, and Wayne’s mother, Gloria, has cancer. Nevertheless, these fictional characters and others in “The Brewsters: An Interactive Adventure in Ethics for the Health Professions” have something to teach all first-year students enrolled at the six schools that make up the university, known informally as UTHealth.

Developed by faculty members at UTHealth’s McGovern Center for Humanities and Ethics, the choose-your-own-adventure novel featuring the Brewster characters was born out of a need for a more integrated approach to introducing the principles of ethics and professionalism to students.

Traditionally at the university and at other academic health science centers around the country, separate ethics courses had been taught at each school. For example, medical students learned about ethics and professionalism in medicine. Nursing students explored ethical issues in nursing and dental students examined ethics in dentistry. But what about the ethical issues that come into play as these health care professionals begin working as teams?

Thomas Cole, Ph.D., professor and director of the McGovern Center, said his group set out to create an interprofessional ethics curriculum that literally put health care teams on the same page. No boring lectures. No boring PowerPoint presentations. It had to be fun. It had to be engaging. And it needed to inspire students to become health care professionals committed to making the right choices.

Led by Jeffrey Spike, Ph.D., professor and director of UTHealth’s Campus-Wide Ethics Program, the McGovern Center team developed storylines that allow readers to see ethical issues unfold, as members of the Brewster family navigate through the health care system and interact with physicians, nurses, dentists, students and researchers.

Should the physician allow Wayne Brewster to have an expensive scan even though it isn’t medically warranted? It sure would help pay the bills for the practice. Should Wayne and Sheila’s teenage daughter be prescribed birth control pills under the guise of acne medication at her mother’s request? What the daughter doesn’t know won’t hurt her, right? There appear to be some irregularities in the data for a clinical trial in which Gloria Brewster is enrolled. Her health could be at risk and so could the research program’s reputation. How should the research assistant handle this?

The reader has the opportunity to role play, make decisions – both good and bad – and see the consequences of those actions. Readers quickly discover that ethical issues are not always black and white, and sometimes even the best decision does not produce the desired outcome.

In addition to the fictional story, the novel includes sections on codes of ethics, professionalism, case studies, policies, protocol and law.

“We think this approach makes it
possible to introduce clinical ethics
in a meaningful way early in a
student’s training, and ultimately
improve patient care.”

—Jeffrey Spike, Ph.D.

“We’re taking this beyond the standard ethics lecture, which didn’t always translate to how you apply the information to your everyday life. This essentially simulates ethical issues in a safe environment,” said Richard Buday, the book’s producer and president of Archimage, a Houston-based visual arts studio that specializes in video game development for the medical research community. “We’re not just trying to educate the students. We’re trying to change attitudes and alter behaviors.”

This is the third year “The Brewsters” is required reading for all new students at UTHealth, whether they be enrolled in the Medical School, School of Nursing, School of Dentistry, School of Public Health, School of Biomedical Informatics or Graduate School of Biomedical Sciences. Students are tested on their knowledge of ethics and professionalism before and after reading the novel.

“Some will argue that you can’t teach ethics,” Spike said. “And some will argue that it’s too hard to teach. We think this approach makes it possible to introduce clinical ethics in a meaningful way early in a student’s training, and ultimately improve patient care.”

Preliminary findings show “The Brewsters” has made a positive impact at UTHealth.

“Each year, pre- and post-tests are given, and students have consistently demonstrated improvement in each area assessed,” said Nathan Carlin, Ph.D., director of the McGovern Center’s Medical Humanities and Ethics Certificate Program.

In the fall of 2012, after reading “The Brewsters,” students showed gains in six areas of assessment. For example, prior to reading the book, only 69.5 percent of first-year students were able to analyze the ethical components of a research study. After reading the book, the number shot to 93 percent. While almost 83 percent were initially able to analyze the reasons why accepting gifts from pharmaceutical companies was problematic, upon completion of the book, almost all of UTHealth’s first-year students – 96 percent – could analyze those reasons.

UTHealth students find “The Brewsters” a refreshing break from lectures and traditional learning, and say it’s preparing them for ethical dilemmas they are likely to face throughout their careers.

“The book creates very realistic scenarios and brings up points I hadn’t considered before,” said Noor Alzarka, a UTHealth student pursuing both a medical degree and a master’s degree in public health. “It doesn’t just explore theoretical aspects of health care. There are practical aspects as well.”

Spike said “The Brewsters” was crafted to be more than just a collection of facts for students to memorize.

“These are focused students who want you to get straight to the point,” he said. “We knew we had a winner when the students’ biggest suggestion was more time to discuss the book.”

Based on the students’ feedback, McGovern Center faculty enhanced the curriculum last year by adding discussions to the required reading and testing. Actors playing the roles of Wayne and Gloria Brewster interacted with first-year students at each of the schools. Students had the opportunity to ask questions, further explore ethical issues and seek opinions from the Brewsters.

During their visit to the UTHealth School of Dentistry, Wayne and Gloria sat at the front of the classroom sipping coffee while telling the students “how it is.” Topics ranged from the ramifications of accepting “a really, really nice” brand-name electric toothbrush to offering incentives such as “free” teeth whitening to patients to attract business.

Buday and Rebecca Lunstroth, J.D., the McGovern Center’s assistant director, facilitated the discussion, at times chiming in with probing questions to prompt discussion. Then the Brewster characters, never at a loss for words, would take it from there.

“These companies aren’t just giving you these things, you know. It’s reflected in the price to the patient and you are essentially helping them advertise their products,” Gloria told the students when the topic of the nice toothbrush came up. “It’s propaganda. It’s all propaganda. You are flies and they are the flypaper, so you better be careful.”

Student Brian Anyanwu said he wasn’t aware just how slippery a slope it could be to accept a gift – no matter how small.

“This book and these discussions really prepare us for the realistic situations we will face throughout our schooling and careers,” he said.

That is exactly the impact the McGovern Center hopes to make with “The Brewsters.”

Exploring topics from plagiarism to research data falsification to sexual harassment to cultural understanding, the book’s intent is to create a common vocabulary for identifying and resolving ethical issues and for respectfully settling differences between members of the health care team.

The eBook version of “The Brewsters” is free to UTHealth students through the university. A softcover version of “The Brewsters” is available on Amazon to health profession students at other schools. A retail version is available on the Apple iTunes iBookstore.

For more information, visit www.MeetTheBrewsters.com.