Original Article

Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting


Although ethics is an essential part of medical education, little attention has been paid to ethics education during the clerkship phase, where medical students observe how physicians make decisions regarding various ethical problems. Specific nuances and cultural contexts such as working in a rural setting can determine ethical issues raised. This phenomenology study aimed to explore ethical issues experienced by Indonesian students during clinical clerkship in a rural setting. In-depth interviews were used to explore students’ experiences. Participants were ten students, selected on gender and clerkship year variations. Data saturation was reached after eight interviews, followed by two additional interviews. Thematic analysis was used in this study, and trustworthiness was ensured through data and investigator triangulation, member checking, and audit trail. Three main themes found in this study were limited facilities and resources, healthcare financing and consent issues, as well as unprofessional behavior of healthcare providers. Many ethical issues related to substandard care were associated to limited resources and complexities within the healthcare system in the rural setting. Early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting.

Carrese JA, Malek J, Watson K, et al. The essential role of medical ethics education in achieving professionalism: the Romanell Report. Acad Med. 2015; 90(6): 744–52.

Myers MF, Herb A. Ethical dilemmas in clerkship rotations. Acad Med. 2013; 88(11): 1609–11.

Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Acad Med. 2011; 86(1): 124–33.

Kenny NP, Mann K V, MacLeod H. Role modeling in physicians’ professional formation: reconsidering an essential but untapped educational strategy. Acad Med. 2003; 78(12): 1203–10.

Sturman N, Farley R, Jennings W. Exploring medical student experiences of ethical issues and professionalism in Australia. International Journal of Practice-based Learning in Health and Social Care. 2014; 2(2): 88–95.

Bloch S. Medical students and clinical ethics. Med J Aust. 2003; 178(4): 167–9.

Rose A, George K, T AD, Pulimood AB. Survey of ethical issues reported by Indian medical students: basis for design of a new curriculum. Indian J Med Ethics. 2014; 11(1): 25–8.

Mejia RB, Shinkunas LA, Ryan GL. Ethical issues identified by obstetrics and gynecology learners through a novel ethics curriculum. Am J Obstet Gynecol. 2015;213(6): 867.e1-867.e11.

Nikavaran Fard N, Asghari F, Mirzazadeh A. Ethical issues confronted by medical students during clinical rotations. Med Educ. 2010; 44(7): 723–30.

Stites SD, Rodriguez S, Dudley C, Fiester A. Medical students’ exposure to ethics conflicts in clinical training: implications for timing UME bioethics education. HEC Forum. 2020; 32(2): 85–97.

Elit L, Hunt M, Redwood‐Campbell L, Ranford J, Adelson N, Schwartz L. Ethical issues encountered by medical students during international health electives. Med Educ. 2011; 45(7): 704–11.

Stites SD, Clapp J, Gallagher S, Fiester A. Moving beyond the theoretical: medical students’ desire for practical, role-specific ethics training. AJOB Empir Bioeth. 2018; 9(3): 154–63.

Ege Moller J, Ronn Clemmensen C, Abdullahi Mohamed N, et al. Medical students’ perspectives on the ethics of clinical reality. Dan Med J. 2020; 67(4): A10190600.

Bowsher G, Parry-Billings L, Georgeson A, Baraitser P. Ethical learning on international medical electives: a case-based analysis of medical student learning experiences. BMC Med Educ. 2018;18(1):78.

Mulyanto J, Kunst AE, Kringos DS. Geographical inequalities in healthcare utilisation and the contribution of compositional factors: a multilevel analysis of 497 districts in Indonesia. Heal Place. 2019; 60: 102236.

Laksono AD, Wulandari RD, Soedirham O. Regional disparities of health center utilization in rural Indonesia. Malaysian Journal of Public Health Medicine. 19(1): 158-166.

Padilla-Diaz M. Phenomenology in educational qualitative research: philosophy as science or philosophical science. International Journal of Educucational Excellence. 2015; 1(2): 101–10.

Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018; 52(4): 1893–907.

Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Education for Information. 2004; 22(2): 63-75.

Braun V, Clarke V. Successful Qualitative Research: A Practical Guide for Beginners,1st ed. London: SAGE Publications Ltd; 2013.

Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Internatiinal Journal of Qualitative Methods. 2017; 16(1): 1–13.

Guion LA, Diehl DC, McDonald D. Triangulation: establishing the validity of qualitative studies. EDIS. 2011; 2011(8): 3.

Karsten J, Jehn K. Using triangulation to validate themes in qualitative studies. Qualitative Research in Organizations and Management An International Journal. 2009; 4(2):123-50.

Muhaimin A, Willems DL, Utarini A, Hoogsteyns M. What do students perceive as ethical problems? a comparative study of Dutch and Indonesian medical students in clinical training. Asian Bioethics Review. 2019; 11(4): 391–408.

Barber SL, Gertler PJ, Harimurti P. Differences in access to high-quality outpatient care in Indonesia. Health Aff (Millwood). 2007; 26(3): w352–66.

Syah NA, Roberts C, Jones A, Trevena L, Kumar K. Perceptions of Indonesian general practitioners in maintaining standards of medical practice at a time of health reform. Fam Pract. 2015; 32(5): 584–90.

Laksono AD, Ridlo IA, Ernawaty E. Distribution analysis of doctors in Indonesia. Jurnal Administrasi Kesehatan Indonesia. 2020;8(1): 29-39.

McCabe R, Healey PGT. Miscommunication in doctor–patient communication. Top Cogn Sci. 2018; 10(2): 409–24.

Ting X, Yong B, Yin L, Mi T. Patient perception and the barriers to practicing patient-centered communication: a survey and in-depth interview of Chinese patients and physicians. Patient Educ Couns. 2016; 99(3): 364–9.

Humayun A, Fatima N, Naqqash S, et al. Patients’ perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of Lahore. BMC Medical Ethics. 2008; 9(1): 14.

Claramita M, Van Dalen J, Van Der Vleuten CPM. Doctors in a Southeast Asian country communicate sub-optimally regardless of patients’ educational background. Patient Educ Couns. 2011; 85(3): e169–74.

Unnikrishnan B, Trivedi D, Kanchan T, et al. Patients’ awareness about their rights: a study from coastal South India. Sci Eng Ethics. 2017; 23(1): 203–14.

Zulfikar F, Ulusoy MF. Are patients aware of their rights? a Turkish study. Nurs Ethics. 2001; 8(6): 487–98.

Claramita M, Nugraheni MDF, van Dalen J, van der Vleuten C. Doctor-patient communication in Southeast Asia: a different culture? Adv Health Sci Educ Theory Pract. 2013; 18(1): 15–31.

Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014; 89(3): 443-51.

Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: a systematic review. Clin Teach. 2013; 10(4): 242–5.

Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016; 50(1): 132–49.

Adarkwah CC, Schwaffertz A, Labenz J, Becker A, Hirsch O. GPs’ motivation for teaching medical students in a rural area-development of the Motivation for Medical Education Questionnaire (MoME-Q). PeerJ. 2019; 7: e6235.

Alkhamees AA, Alaqil NS, Alsoghayer AS, Alharbi BA. Prevalence and determinants of burnout syndrome and depression among medical students at Qassim University, Saudi Arabia. Saudi Med J. 2020; 41: 1375-80.

Erniaty E, Harun H. Understanding the impacts of NPM and proposed solutions to the healthcare system reforms in Indonesia: the case of BPJS. Health Policy Plan. 2020;3 5(3): 346–53.

Smith SK, Nicolla J, Zafar SY. Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study. J Oncol Pract. 2014; 10(5): e368–72.

Warsame R, Kennedy CC, Kumbamu A, et al. Conversations about financial issues in routine oncology practices: a multicenter study. J Oncol Pract. 2019; 15(8): e690–703.

Yuliyanti C, Thabrany H. Delayed claim payment and the threat to hospital cash flow under the national health insurance scheme in Indonesia. [cited on June 2021]; https://scholar.ui.ac.id/en/publications/delayed-claim-payment-and-the-threat-to-hospital-cash-flow-under-

Susilo AP, Nurmala I, van Dalen J, Scherpbier A. Patient or physician safety? Physicians’ views of informed consent and nurses’ roles in an Indonesian setting. J Interprof Care. 2012; 26(3): 212–8.

Mueller PS. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med. 2009; 58(3): 133–43.

Stern DT. Measuring Medical Professionalism. New York: Oxford University Press; 2006.

Stowell NF, Martina S, Nathan W. Healthcare fraud under the microscope: improving its prevention. Journal of Financial Crime. 2018; 25(4):1039–61.

Sheldon T. Dutch neurologist found guilty of fraud after falsifying 438 case records. BMJ. 2002; 325(7367): 734.

Mercer SE, Tino A. Falsifying medical records: a systems approach investigation. Journal of Nursing Regulation. 2011; 2(3): 41–3.

Vatikawa A, Amnawaty A. Medical record data counterfeiting by doctors in Indonesia reviewed from the ethics, discipline, and legal aspects. Fiat Justisia. 2018; 12(3): 224–33.

Lantos JD, Meadow WL. Should the “slow code” be resuscitated? Am J Bioeth. 2011; 11(11): 8–12.

Sak-Dankosky N, Andruszkiewicz P, Sherwood PR, Kvist T. Preferences of patients’ family regarding family-witnessed cardiopulmonary resuscitation: a qualitative perspective of intensive care patients’ family members. Intensive Crit Care Nurs. 2019; 50: 95–102.

Binder R, Garcia P, Johnson B, Fuentes-Afflick E. Sexual harassment in medical schools: the challenge of covert retaliation as a barrier to reporting. Acad Med. 2018; 93(12): 1770–3.

McClain T, Kammer-Kerwick M, Wood L, Temple JR, Busch-Armendariz N. Sexual harassment among medical students: prevalence, prediction, and correlated outcomes. Workplace Health Saf. 2021;69(6):257-67.

Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014; 89(5): 817–27.

Ahmer S, Yousafzai AW, Bhutto N, Alam S, Sarangzai AK, Iqbal A. Bullying of medical students in Pakistan: a cross-sectional questionnaire survey. PLoS One. 2008; 3(12): e3889.

Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ. 2004; 329(7469): 770-3.

Easteal P, Ballard AJ. Shutting-up or speaking-up: navigating the invisible line between voice and silence in workplace bullying. Alternative Law Journal. 2017; 42(1): 47–54.

Martin JS, Ummenhofer W, Manser T, Spirig R. Interprofessional collaboration among nurses and physicians: making a difference in patient outcome. Swiss Med Wkly. 2010; 140: w13062.

Vyt A. Interprofessional and transdisciplinary teamwork in health care. Diabetes Metab Res Rev. 2008; 24(Suppl. 1): S106–9.

Hanum C, Findyartini A. Interprofessional shared decision-making: a literature review. [Jurnal Pendidikan Kedokteran Indonesia] The Indonesian Journal of Medical Education. 2020; 9(1):81-94

Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med. 2012; 42(6): 704–11.

Guertler AT, Cortazzo JM, Rice MM. Referral and consultation in emergency medicine practice. Acad Emerg Med. 1994; 1(6): 565–71.

Finlay S, Sandall J. “Someone’s rooting for you”: continuity, advocacy and street-level bureaucracy in UK maternal healthcare. Soc Sci Med. 2009; 69(8): 1228–35.

DuVal G, Clarridge B, Gensler G, Danis M. A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004; 19(3): 251–8.

Haeranah, Patittingi F, Muhadar, et al. Health and law: euthanasia in Indonesian legal perspective. Enfermeria Clinica. 2020; 30(4): 492–5.

IssueVol 14 (2021) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/jmehm.v14i6.6750
Ethical issue; Medical students; Clinical clerkship; Indonesia.

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Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Wicaksono R, Ferine M, Lestari D, Hidayah A, Muhaimin A. Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting. J Med Ethics Hist Med. 14.