University of Sydney Medical Program

University of Sydney Medical Program Involving Patients in Medical Education: Ethical guidelines for medical students and clinical teachers Introduction Learning to be a good doctor requires practical clinical experience involving patients. One of the most valuable parts of the Sydney Medical Program is the opportunity for students to learn medicine at the bedside. This necessarily involves students in observing the full range of patients emotional and physical experiences. It is important that students remember that their opportunity to interview and examine patients is a privilege that is granted by each individual... Patients should not be involved in any activities involving personal communication or physical touch without their express permission. A patient may withdraw this privilege at any time and for any reason. Particular care must be taken when involving patients in teaching activities because, from the patient s perspective, student learning is not directly necessary for their care and treatment. Nevertheless most patients welcome the opportunity to contribute to the education of students and junior doctors. Explicit guidelines for clinical teachers and medical students provide protection for everyone. They are designed to protect patients, to promote high ethical standards and to avoid misunderstandings. Bed Side Teaching Clinical teachers must ensure that patients understand that medical students are not qualified doctors. When introduced to patients or their families they should always be described as medical students. Please do not describe students as junior doctors, student doctors, young doctor s, assistants or colleagues. Students must advise patients of their correct status, even if that means correcting what their clinical teacher has said. Students must explain that they are medical students studying to become doctors. Patient consent Clinical teachers must advise patients that their cooperation in educational activities is entirely voluntary. Clinical teachers and medical students must obtain verbal consent from patients before student s interview or examine them. Patients should be told that the examination is mainly for educational purposes. An appropriate form of words is Would you mind if these students ask you about your illness and/or examine you so that they can learn more about your condition? Please take care to ensure that patients understand that their participation is voluntary and that a decision not to participate will not compromise their care. While verbal consent is sufficient for most educational activities students should be aware that the law requires patients to be fully informed, in advance, about their care and treatment. Much of health care requires written consent. If a student is unsure about the type of consent required they should check with a clinical supervisor. 1

When education is an integral part of clinical care If a student has a learning opportunity that involves assisting, observing or examining a patient during the patient s treatment or therapy then specific verbal consent is not necessary, as long as the patient is aware that students may be involved in their care and treatment. For example when a patient is in theatre and the surgeon directs the student to assist or to perform a relevant examination, then separate consent is not necessary, provided that the activity is directly related to the patient s management. Supervisors must obtain consent for students to conduct a physical examination and also for other students to be present during the examination. A suitable form of words is simply Would you mind if (student X) examines you while we observe? Students requesting supervision There will be times when students want supervision but it is not available because of other ward activities or patient care load. Notwithstanding these competing interests it is important that students ask for supervision when they think they need it. If the supervision is not immediately available then a time should be scheduled with the appropriate person (Doctor or nurse) so they can supervise the student during the procedure. Students have obligations to do the following before they first perform the procedure on a patient: Read about the procedure and how it is done. Observe another person perform the procedure Practice the procedure on a model or surrogate patient Arrange for a supervisor to be present when the student is performing the procedure for the first time A patient must give prior written consent to any invasive intimate physical examination such as a rectal or vaginal examination under general anaesthetic when it is for primarily educational purposes separate from treatment. The prior written consent must indicate the nature of the examination intended and must be recorded in the medical notes. Patients who are unconscious or incompetent for other reasons must only be involved in such examinations with the explicit written agreement of their responsible clinician and after appropriate consent from a parent (if a child) appropriate relative or appointed guardian (if adult). Clinical teachers and students must obtain explicit verbal consent from patients for procedures such as taking blood, suturing or giving injections. If the procedure is one that is normally written in the notes, then consent must also be recorded. Procedures that do not require supervision are only to be performed if the supervisor/staff member has satisfied him or herself that the student is competent to perform the procedure. 2

Patient confidentiality Medical students must respect the confidentiality of all information to which they have access whether or not it is related to patients condition or treatment. Clinical teachers and medical students must respect patient confidentiality when discussing a patient in any way. Students must never provide information that would identify a patient unless there is a clear need to know. Students must obtain a patient s written authorisation to record identifying information that they intend to use for educational purposes. An educational purpose is when the activity is undertaken separately from the care and treatment of a patient and the explicit intention of the activity, contact or communication is educational. Medical students must not discuss cases in public places such as lifts, corridors, coffee shops, and waiting rooms where a third party can overhear their conversation. This is the case even if the patients names are not used. Patients must be informed if medical students may, in the patient s best interests, be obliged to divulge confidential information to a responsible clinician about the patient s care and treatment. An example would be a patient who expressed the intention of self harm. Medical records Medical students must identify themselves and their status in the medical record. They must take care to record only information they believe to be factual and accurate or representing accurately the words of the patient or the patient s relatives. ETHICAL DILEMMAS Several studies highlight the problem of the hidden curriculum in medical education. Students report that the most difficult situations to resolve involve teachers who appear to show unethical 2, 3, 4, 5, 6 behaviour towards patients Hicks et al surveyed 108 clinical students one year from graduation at a medical school in Toronto. Forty seven percent of students reported that they had been at times placed in a clinical situation in which they felt pressured to act unethically. Sixty one percent said they witnessed a clinical teacher acting unethically very frequently, frequently or occasionally. 7 This same study reported that ethical problems reported by the students were seldom discussed or resolved with the clinical teachers. All students and doctors in training potentially face similar ethical dilemmas. There may be rare occasions where clinical supervisors direct medical students to participate in patient management that are perceived by the student to be unethical or misleading to the patient. Many students are not confident to raise the appropriateness of such involvement with their supervisors and are unsure of how to act. This role confusion can lead to student stress and can have a negative impact on morale and the students developing professionalism. 3

WHAT STUDENTS SHOULD DO Students should be aware of their legal and ethical obligations to put patient interests first 8. This may include refusal to comply with an inappropriate instruction or direction. The best way to resolve the conflict (or at least gain a different perspective) is for the student to speak directly with the person concerned in private. The patient concerned should not be part of this discussion. The student should explain the problem(s) and why they are unable to comply with the instruction or direction. If the clinician or responsible staff person ignores the issues raised and continues to instruct the medical student to proceed s/he should use discretion to proceed or withdraw from the situation. If s/he decides to continue patient consent must be confirmed. If the patient does not consent the student must not proceed. If a patient is unconscious or anaesthetised the student should explain why they cannot proceed. It may be necessary to point out the requirement of the Sydney Medical School to comply with these guidelines. It may also be appropriate to discuss the situation with another person in the faculty or clinical school. If a medical student is uncertain about the appropriateness of any behaviour by any other person involved in patient care, s/he should discuss the matter with a senior colleague of choice, usually the Associate Dean. Any student who feels that s/he has been subjected to unfair treatment because of a refusal to do something that seems to be wrong should seek advice from senior colleagues. If necessary a student may seek the support of the NSW Medical Board, the Health Care Complaints Commission or other appropriate authority. STUDENTS' RESPONSIBILITIES TO EACH OTHER Every member of a profession has a responsibility for the standards of the profession as a whole. If a student has reason to believe that a fellow student is impaired, s/he has a professional responsibility to report thematter to a faculty member. This duty to report overrides any obligations regarding confidentiality between students. Encourage the impaired student to self report, but if they refuse ask them to nominate the person whom they would prefer to receive information about them. If the impaired student cannot nominate such a person the worried student needs to report the matter to the Associate Dean. Students may find the following form of words helpful in discussing reporting with the fellow student I need to report (the matter of concern). I m happy to negotiate concerning whom I should tell and how much I should tell, but I am not willing to keep this problem a secret. 4

CLINICAL TEACHERS' RESPONSIBILITIES TO STUDENTS Students are sometimes unsure about raising ethical issues with their clinical teachers because they fear they may be discriminated against if they are perceived to be trouble makers or soft. This is unfortunate, since ethical issues are interesting and challenging. They raise important learning opportunities. Students should be encouraged to raise ethical issues with teachers throughout the term and not just when a specific issue arises. They should also be encouraged to speak directly with the teacher involved in an ethical dilemma. Because students are new in the hospital environment they may be mistaken in assuming that their position is being compromised. A simple explanation about the reasons for managing a patient in a particular way may be sufficient for the student to gain new understanding. Teachers should be receptive to ethical dilemmas or problems that students raise and seek to explain the ethics involved, or change the circumstances so that students are not ethically compromised and patients are respected. If there is a particular practice that is routine in the hospital environment, but raises ethical issues for medical students the matter should be discussed with the Associate Dean of the clinical school, because s/he is in a position to resolve the issue at a systems level. PROBLEMS IN THE WORKPLACE Like all workplaces, hospitals and other health facilities are legally required to protect their staff (including students) from harassment. A study 9 involving students in an Australian university medical school showed that female students encountered an unacceptable amount of sexual harassment in medical training from fellow students, patients, faculty and doctors they worked with. 293 students returned questionnaires out of 310. The results showed that the type of behaviour most reported concerned inappropriate comments by fellow students. Complaints against patients ranked second with concerns about unwelcome attention and unwanted physical contact. Faculty members and doctors were mainly criticised for inappropriate comments. Research shows that medical students in other countries have similar problems. W hat is sexual harassment? Generally this is sexually related behaviour that: a person does not want offends, humiliates or intimidates you In the circumstances, a reasonable person should have expected would offend, humiliate or intimidate you. Is harassment and sexual harassment at work against the law? Yes. Under the NSW Anti Discrimination Act it is against the law for you to be harassed at work because of your: sex, pregnancy, race, marital status, disability, homosexuality, transgender and age. 5

What to do You can privately ask the person to stop the behaviour. You can seek the assistance of a clinical tutor You can seek the assistance of a faculty member You can seek the assistance of the Associate Dean The hospital will have a protocols and an identified officer to provide advice and guidance on how to deal with a problem of harassment. 1 These guidelines are adapted and expanded from "Policy on the rights of patients in medical education" BMJ 2001:322:685 686 2 Hicks LK. Lin.Y Robertson DW Robinson DL. Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study BMJ 2001;322:709 710 3 Swenson SL. Rothstein JA. Navigating the wards: teaching medical students to use their moral compass. Acad Med 1996;71:591 594 4 St Onge J Medical education must make room for student specific ethics dilemmas. Can Med Assoc J 1997;156:1175 1177 5 Bisonette R. O'Shea RM. Horwitz M. Route C.F A data generated basis for medical ethics education: categorisating issues experienced by students during clinical trials Acad Med 1995;70:1035 1037 6 Feudtner C. Christakis DA. Christakis NA. Do clinical students suffer ethical erosion? Students' perceptions of their ethical and personal development Acad Med 1994;69:670 679 7 Hicks LK. Lin Y. Robertson DW. Robinson DL. Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study BMJ 2001:322:709 710 8 NSW Medical Board, Health Care Complaints Commission, Area Health Service Boards, Quality Councils, credentialling bodies. 9 White GE. Sexual Harassment during medical training: the perceptions of medical students at a university medical school in Australia Medical Education 2000;34:980 86 Contact: Merrilyn Walton, Associate Professor of Medical Education, OPME (Email) mwalton@med.usyd.edu.au (Phone) 9351 3678 6