Presented By: Melissa Armas, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine
Co-Authors: Karla Carvajal, Florida International Universit Herbert Wertheim College of Medicine
Gloria Coronel-Couto, Florida International University Herbert Wertheim College of Medicine
Amala Landa-Galindez, Florida International University Herbert Wertheim College of Medicine

Purpose
Medical students may feel ill-prepared to handle ethical dilemmas experienced during clinical rotations, with resultant moral distress. We aimed to study ethical dilemmas experienced by students during their FIU Herbert Wertheim College of Medicine Internal Medicine (IM) Clerkship, and to specifically assess challenges related to Social Determinants of Health (SDOH). 

Methods 
A reflective assignment was introduced in the IM clerkship where students were asked to describe a witnessed ethical dilemma. Students were asked to describe the clinical scenario, ethical issue, emotional response(s), professional obligations, and alternative management approach/values. Interactive small-group debriefing sessions were introduced where students  discussed individual cases and then presented to the larger group. 

Results 
357 assignments were deidentified. Authors reviewed/categorized them into primary ethical themes: social/organizational, lack of professionalism, patient privacy/confidentiality, shared decision-making, and primacy of patient welfare. Moral distress was determined by consensus based on emotionally-charged words. 33% of analyzed assignments contained themes in social/organizational ethics. 88% of analyzed assignments presented with moral distress. Words such as frustrated, helpless, and ashamed described strong emotional responses. Preliminary data from small group debriefing sessions suggests that 45% of the cases presented by the students were related to SDOH. Important issues included homelessness, immigration/insurance limitations, and substance abuse. 

Conclusions 
We found numerous examples of moral distress and ethical challenges faced by students during clinical rotations related to SDOH. Sample problems included lack of insurance limiting ability to receive life-saving interventions or adequate follow up care as well as cases related to immigration status, incarceration, and substance abuse. Debriefing sessions provided students with resources and opportunities to discuss viable options to address similar future challenges with patients/caregivers. Students reported that discussion of care strategies was empowering, and the reflective sessions left them better prepared for future challenges in patient care.