Abstract
BACKGROUND: As undergraduate medical students are acculturated into clinical practice, they develop a set of refined professional values that impact their decision making. We aimed to use students' reflective narratives on ethical dilemmas to identify how students experience moral distress while working in the emergency department (ED) to better understand how to support them in the development of their own agency to act ethically. METHODS: Students rotating in our emergency medicine clerkship are required to submit an essay describing an ethical dilemma they encountered. We selected a random sample of these reflective pieces from the 2015 and 2016 academic years and used an exploratory qualitative thematic analytic approach to identify frequently recurring themes. This process was continued until thematic sufficiency was reached. RESULTS: Two-hundred essays were coded, and seven unique themes were identified. The moral distress students described in reflective writing narratives stemmed from patient-provider discord, uncertainty, and social injustices. In each case, students were expressing the cognitive dissonance they experienced as they began to reconcile the difference between their perceptions of optimal patient care and the actual care delivered to the patient. CONCLUSION: Understanding medical students' cognitive dissonance in the ED will help educators support their students as they negotiate the differences between preferences and principles while being acculturated into clinical practice. Future work should develop specific interventions to promote educator understanding of learners' moral distress and to develop novel models of support for learners.