Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 49, Num. 2, 2003, pp. 159-162

Journal of Postgraduate Medicine, Vol. 49, No. 2, April-June, 2003, pp. 159-162

Ethics Forum

Ethics of Patient Care by Trainee-Doctors in Teaching Hospitals

Sethuraman KR

Departments of Medicine & Medical Education, JIPMER, Pondicherry - 605006, India.
Address for Correspondence: K. R. Sethuraman, MD, Departments of Medicine & Medical Education, JIPMER, Pondicherry-6, India. E-mail: krs@jipmer.edu

Code Number: jp03042

Education without character is like a body without its head.

- Rabindranath Tagore. Bengali poet & playwright; 1913 Nobel Prize for Literature.

It is the aim of the teaching hospitals to provide the trainees and the supervising clinician-faculty with an environment conducive to teaching and learning without compromising the quality of patient care in any way. In contrast to the traditional learning in a classroom, clinical learning includes all activities undertaken by a trainee in providing patient care.

An ethically sensitive teacher often faces the dilemma of having to balance between one's duty as a teacher to train the students well and duty as a clinician to do the best for the patient. The essence of this dilemma is - beneficence to students versus non-maleficence to patients. This can only be sorted out by careful introspection - "Is patient welfare being compromised to accommodate the needs of the students?"

Some Common Scenarios in India

• An unsuspecting "teaching material" - also known as a general ward patient with a clinically interesting problem or disease - is wheeled in to a large seminar hall where a "Grand Round" will be held shortly.
• Several students examine a female patient with "good findings" per vaginum.
• An "examination case" - for example, a massive pleural effusion or a breast tumor - is kept in the ward for several days without appropriate intervention until the university examination is over.
• Regardless of the complexity of the surgical problems, the student trainees get to operate on patients from the free wards while the consultant takes charge of the "private cases."

An ethically sensitive person recognises violation of principle of equality in the above examples. In addition, the principle of autonomy is also violated when no freedom of choice is given to the patients being treated by the trainees. The clinician-teacher is paternalistic in allotting patients for procedures to be done by trainees.

Students' Perspective

During the clinical training, medical students are subject to high levels of stress, and some may not cope with it well. Due to their youth and immaturity, they may be emotionally unprepared for experiences of diseases, suffering, and death. In such instances, the emotional price of clinical training can be enormous.¹

Previous research indicates that medical students often experience ethical dilemmas concerning patient-care. Three types of ethical dilemma are characteristic of early clinical training:

• Conflict between medical education and patient care
• Responsibility exceeding student's capabilities
• Involvement in care perceived to be substandard

Research also suggests that these dilemmas are seldom resolved during medical school.²

Conflict Between Medical Education and Patient Care

The conflict between educational needs and ethical requirements is especially acute in the teaching of intimate examinations. On the one hand, intimate examinations are not particularly risky procedures, although the patient may have some pain or discomfort, loss of privacy, and potentially psychological damage. Traditional teaching of these procedures was guided by a utilitarian ethic_that learning how to do intimate examinations would benefit future patients by improving standards of care. More recently the invasive and potentially disturbing aspect of these procedures has been recognized.³

Responsibility exceeding student's capabilities

Several examples have been recently published of which two are cited here. The Prison Service of UK was sharply criticised by an independent inquiry into the death of a prisoner who had an attack of asthma in his cell. The 33-year old prisoner died in 1996. The junior doctor charged with his care had been forbidden earlier by the General Medical Council to practise unsupervised.⁴ An eminent professor of gynaecology was accused of delegating surgery to a junior who lacked the competence to perform the procedure and had to appear before the General Medical Council of UK.⁵

Involvement in Care Perceived to be Substandard

A recent book on "Ward ethics" examines the dilemmas created in trainees by demands to do things beyond their level of competence and the pressure to do substandard things to protect their personal progress. The editors of the book point out, `- there is a danger of professional hypocrisy in any system that proclaims a dedication to the goal of producing humane and compassionate physicians while allowing institutionalised behaviours that undermine that effort.'⁶

Indian Consumers' Perspective

The author had an interesting and revealing experience during the summer of 1995 when FEDCOT (the Federation of Consumer Organizations of Tamil Nadu) had organized a 4-day summer camp on health related consumer issues.⁷ During the session on consumer rights in healthcare, the participants, who represented over 140 consumer groups of Tamil Nadu were asked to comment on the rights of the patients in teaching hospitals. After much deliberation, the working group presented the following points in the plenary session:

• In order to prepare the next generation of doctors and allied professionals, it is essential to have teaching hospitals functioning optimally.
• To ensure that our children and subsequent generations get competent healthcare, it is necessary for us -the present generation- to willingly and actively take part in the training programme of the teaching hospitals in whatever capacity required of us by the senior faculty staff. Only such a co-operation from us the consumers can ensure that the current batch of trainee doctors emerge with confidence and competence to treat our descendants.
• As a reciprocal gesture to this altruistic behaviour of the patients, the teaching faculty must ensure that the patients are not exposed to any avoidable harm during the training process, whether it involves taking a class or operating on them or using them as examination cases.
• Whenever consumers enter a teaching hospital, it is known that trainees will be involved in providing healthcare. While such implicit acceptance is readily conceded, it is better for them to be reassured that no risky procedures or experiments will be conducted on them without their explicit consent.
• Finally, government and the private organisations spend a lot of resources in maintaining the free beds in teaching hospitals. In return for such free services, the patients are obliged to accept a certain amount of "harmless inconvenience" like being physically examined by students, being kept in examination hall as cases or being taken for discussions and seminars.

It was a revelation to find such maturity and wisdom among consumers on the matter of patients' rights and obligations in teaching hospitals. They approached the problem on the basis of utilitarian ethics, so characteristic of "Consumerism" and clearly spelt out mutually acceptable solutions.

Faculty Perspective

Ethical sensitivity can be cultivated by asking oneself, "Would I like my near and dear to be treated thus?"⁸ In addition, one can adopt ethical guidelines proposed for patient-friendly institutions. For example, the University of Toronto has developed guidelines on ethics in clinical teaching for its affiliated teaching hospitals.⁹ Recently, British policy on the rights of patients in medical education was spelt out.¹⁰ Based on the consumers' suggestions cited earlier and to suit Indian context, these guidelines can be modified as a sort of ethical framework for our colleges.

Ethical Guidelines for Clinical Teaching and Learning

A teaching hospital should -

• Be committed to excellence in patient care, teaching and research and to high quality skill-oriented training of all the trainees. If such institutional goals are clearly perceivable, the public will willingly get treated in these "teaching hospitals" and not report there as a last resort.
• Be convinced that clinical teaching-learning is a vital component in the development of trainees as the future healthcare providers. If teaching hospitals ignore training of the students in order to keep the patients away from any risks during learning process, then the next generation of health care professionals will be poorly trained and ill-equipped to perform their job with competence.
• Convey to all the patients that the institution is a learning environment and that trainees are an integral part of patient care. The residency scheme and clinical-clerkship are some examples of making the trainees an integral part of the healthcare team. They need to be given graded responsibilities-lists of dos and don'ts- to facilitate learning without compromising safety.
• Accept a patient's right to be informed about any specific teaching activity in which he or she will participate. Obtain verbal consent from patients before asking them to participate as a "teaching-learning resource" for the trainees
• Accept that patients have the right to refuse to participate in activities that are purely academic in nature (e.g. bedside clinics for trainees, be a "live exhibit" in seminars, rounds, etc.). If it is unethical to even publish identifiable pictures of patients in scientific publications, is it not a patient's privilege to refuse being a live exhibit? If the treating team has a good rapport with the patient and if it is assured that patient will not be harmed or humiliated in the proposed activity, most of them would not mind taking part willingly.
• Accept that the patients have a right to know the trainees who may be involved directly in their care under the supervision of seniors or faculty clinicians; the onus is on the supervising clinician to suitably inform them. A good word from the unit chief goes a long way in effecting this without letting the trainee down. When I was a PG resident, my chief used to tell the patients especially those in the private ward that I was the brightest boy in his team and therefore I would look after them. Such an introduction galvanised me to do my best.
• Define various invasive procedures that require a patient's written consent prior to a trainee's participation in any such invasive procedures.
• Ensure that effective supervision is available to prevent any harm to the patients when the trainees learn skills by hands-on experience.

Ethical Guidelines for the Faculty

• Be committed to ethical conduct in teaching activities, especially integrity and honesty in dealing with trainees as well as the patients.
• Recognise the value of being a role model to trainees for ethical practice especially in professionalism, confidentiality and treating all the patients -regardless of their social status, educational level, religion, age or gender- with dignity and respect.
• Be open to questioning by trainees on what constitutes ethical practice in situations of ethical dilemma. Socratic method of learning by questioning is effective in shaping ethical dimension in the students. Provide trainees with opportunities to discuss any ethical problem they may face.
• Ensure that every trainee feels obliged to refuse to participate in patient care or clinical teaching if he/she has concerns regarding i) his/her own competence or ii) about the adequacy of supervision or iii) has ethical concerns about the proposed activity.
• While accepting a learner's refusal to participate in patient care activities or clinical teaching on ethical grounds, help him sort out the problems in a productive manner.
• Be responsible for continuous evaluation of trainees' competence to determine the level of supervision that each of them require and the degree of delegation that each of them can cope with. Giving graded responsibility to each of the trainees is perhaps the greatest challenge for a conscientious trainer.

To sum up, it needs to be stressed that fostering ethical awareness in our students requires us, the teachers, to change our attitudes for the better and be role models for the next generation. As the moving force in teaching institutions, the onus is on us to form hospital ethical committees and promote patient-friendly initiatives and usher in effective clinical training without causing public resentment.

Summary

Teaching hospitals and medical schools need to become sanctuaries of respect for human rights and dignity. Making clear to the faculty staff and the students that attitudes and behaviour that have so damaged the reputation of doctors, no longer have a place in medicine is an important step. This will help in alleviating stress among students who are under pressure to perform acts of questionable ethics, often against their personal beliefs based on youthful idealism. Such a metamorphosis will also help to ensure that the students of today will be proud rather than distressed that they have chosen to be the doctors of tomorrow.¹

"The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind."

- William James. American philosopher-psychologist, 1842-1910

References

1. Doyal L. Editorial - Closing the gap between professional teaching and practice. BMJ 2001;322:685-6.
2. HicksLK , Lin Y, Robertson DW, Robinson DL, Woodrow SL. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ 2001;322:709-10.
3. Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations-teaching tomorrow's doctors. BMJ 2003;326:97-101.
4. Dyer O. Prison doctor should not have worked unsupervised, says inquiry. BMJ 2002;325:122.
5. Dyer O. Gynaecologist accused of delegating inappropriately. BMJ 2002;325:616.
6. Ward Ethics. Dilemmas for Medical Students and Doctors in Training. In: Thomasine KK, Thomasma DC, eds. Cambridge: Cambridge University Press; 2001.
7. Sethuraman KR, Oumachigui A. Consumer rights in healthcare. Proceedings of the summer camp on "Healthcare issues for the consumer" - May 1995. FEDCOT, Kodaikanal, Tamil Nadu. (Unpublished data on file).
8. Sethuraman KR. Trick or Treat - a survival guide to healthcare. Pondicherry-605006: Society of EQUIP (P.B. No 8), 2000.
9. University of Toronto. Guidelines for ethics in clinical teaching. Toronto: University of Toronto, 16 May 2002. www.library.utoronto.ca/medicine/educational_programs/guidelines.pdf (Accessed 2 Mar 2003).
10. Anonymous. Policy on the rights of patients in medical education. BMJ 2001;322:685-6.

Copyright 2003 - Journal of Postgraduate Medicine. Online full-text also available at http://www.jpgmonline.com/