Bioethics Discussion Blog: Patient Responsibility: "Consider Participating in Medical Education"

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Sunday, June 25, 2006

Patient Responsibility: "Consider Participating in Medical Education"

Continuing on with the topic of patient responsibility which was mentioned in the Comment section of the last post on the “Tired Doctor”, there is an article titled “A Responsible Patient” in the April 2003 issue of "Virtual Mentor. In the article, the American Medical Association's Code of Medical Ethics, Opinion 10.02 , regarding patient responsibilities is quoted as

“to include, but not limited to the responsibility to:
1. Be truthful and express their concerns clearly to their physicians.
2. Provide as complete medical history as possible .
3. Request information or clarification when they do not fully understand their health status or treatment.
4. Cooperate with agreed-upon treatment plans and appointments.
5. Take personal responsibility when they are able to prevent the development of disease.
6. Consider participating in medical education by accepting care from medical students, residents, and others”


I was particularly intrigued by item 6 “Consider participating in medical education by accepting care from medical students, residents, and others”. I wondered whether patient’s entering a clinic or hospital for medical or surgical treatment really enter expecting they should consider being possibly altruistic by accepting care from “medical students, residents and others” as part of contributing to medical education.

Medical training hospitals routinely may have a statement about medical education, usually in small print, somewhere on their admission papers for the patient to sign but do patients really understand what is going on? Is there specific or verbal communication by the hospital or the patient’s personal physician about what is going on? How do patients feel about being interviewed, examined or cared for as part of medical education if they learn about this before the experience or only afterward?

As teachers of first and second year medical students, we routinely and directly ask patients if they would approve having a medical student interview and examine them, explaining what the student would be doing. If the patient, for whatever reason, rejects the offer, the patient is not criticized but we go on and try to find another patient. Since I don’t participate in medical education in the later years, I am not fully aware of the timeliness or degree of informed consent that is given to patients. But I suspect that it is not the same as what we do in the first two years.

I,personally, would be greatly interested in comments by physicians and patients about this subject. One particular point that I would be interested in knowing is whether physicians, themselves, would accept examination and care by those still formally learning. ..Maurice.

9 Comments:

At Monday, June 26, 2006 9:26:00 AM, Anonymous Anonymous said...

Before discovering that doctors hide mistakes I would have felt allowing a medical student to gain experience, via being exposed to as many different patients and situations as possible, was an obligation. I would have ignored my comfort level in trade for viewing this as a ‘big picture’ process and for the ‘greater good.’ I would now feel no obligation and would refuse to participate. I would view the medical student as being someone who was being indoctrinated into a ‘club’ where there are two sets of rules. One set for the patients and one for the doctors. That while I viewed allowing this as a ‘greater good for future patients’ the medical community would view ‘it’ as a slab of tissue to be examined and learned from so the student could move closer to earning a living. I would 100% believe if a mistake was made during this process the medical student would then be taught how to manipulate and control the situation to the benefit of the medical community. Obviously a cynic has been born and my perspective should be viewed as such.

 
At Monday, June 26, 2006 12:38:00 PM, Blogger Maurice Bernstein, M.D. said...

I try to teach the first and second year medical students humanistic medicine and that means thinking about the patient first before onself. However, what happens later in their career I have no control. For years, defense lawyers for insurance companies and risk management people within hospitals have been preaching to physicians regarding experiencing medical error: against apology, against revealing the facts to anyone beyond their lawyers or admitting any mistake or wrongdoing. This sermon was not something which originated by the physicians themselves but came from those whose professions were to "manage" the medical risks, obviously for their self-interest (as well as, of course, the doctors'). Nevertheless, in recent years, there is evidence that physician improved communication and openness especially with regard to medical error may not be as self-damaging as previously thought. There is now a beginning change in the sermon to physicians: think about promptly admitting error to the patient,family and system, apologizing to the patient and family but with empathetic understanding and for hospitals to do the same and to consider compensation. It has been found, though studies are still continuing, that there may be less patient and family upset, more understanding, less patients leaving physicians and no major increase in malpractice suits filed, maybe even less. Hopefully, the results of these studies will be placed in a new sermon for preaching to physicians. They certainly are supportive of the humanistic medical behavior we are teaching our medical students. ..Maurice.

 
At Wednesday, June 28, 2006 6:44:00 AM, Anonymous Anonymous said...

I’ve read a few articles on encouraging doctors to admit mistakes based on the belief that many malpractice suits are driven by patient anger. This makes a great deal of sense.

By admitting a mistake a doctor is admitting to being human. That’s a great starting point in communication and improving care. By hiding a mistake it’s as if the doctor thinks he or she is above the rules applied to mere mortals. This attitude degrades the doctor in the eyes of the patient. There is, as mentioned by another contributor, the sense that the patient is viewed as being so stupid he or she doesn’t know a mistake was made. Or, doctors are so arrogant their image/ego is more important than patient wellbeing. It is a natural reaction to become angry when insult is added to injury.

I liken it to a person being hit from behind by a car and witnesses, simply because they are on the same team as the driver, pretending there was no car. The victim knows there was a car. In a perfect world medical staff and patient would sit down together, gather all the data possible and form a clear factual picture of what took place. A fair and reasonable conclusion would be reached and a valuable lesson learned. This might mean an apology, a promise to correct whatever caused the mistake, and compensation where needed. For this approach to work it cannot be allowed to degrade into lip-service to avoid being sued, while on the other side it cannot be allowed to degrade into automatic cash payouts. It might be helpful to constantly remind participants that the main goal is to discover what went wrong and correct the problem. This, without downgrading the event.

 
At Friday, June 30, 2006 10:58:00 AM, Blogger Hans G. Engel, M.D. said...

In training junior and senior medical students, I found it useful to have students examine, evaluate and "diagnose" patients - under very specific conditions.
Patients had to freely agree to the routine, professors or instructors observed communication through a one-way mirror and microphone. On completion of the meeting, the patient would wait while the results were discussed between the teacher and student and appropriate action was then taken.
On many occasions other professors and I served as patients, commenting on errors, new information and answering questions regarding our own disabilities (even including fictional disorders at times).
In my experience, on more than one occasion, my student was better informed on an issue that I was!

 
At Saturday, July 01, 2006 11:40:00 AM, Blogger Robin said...

I am a transplant recipient (the organ I received is implicit in my screen name, kidnykid). I have noticed that only in recent years have doctors introduced med students as such, and secured my permission to have the students and residents participate in my care. When I was transplanted 27 years ago, such permission was almost never obtained from the patient; one was simply expected to accept that one would be examined by med students, residents and clinical fellows of either gender, without argument.

 
At Monday, July 03, 2006 1:02:00 PM, Anonymous Lindsay said...

I have never had a problem with allowing an examination/consultation with a student. Until I was pregnant for the first time and felt that I wanted there to be as few people in the delivery room as possible, and that I wanted control over who those people were.

I specifically requested that there be no students present at any time during my labor and delivery, but that I would allow students access as appropriate during the post-partum stay.

My wishes were disregarded and there were at least two students (and an escort?) present as I pushed out my son. I found it distracting and uncomfortable, and am angered enough to say that I don't want any med/healthcare students around me at all again. It's not logical, but I feel like my wishes should have been followed at this most intimate time and as I had no control then, I will exert control later on when I can- probably to the detriment of the learning process, I am a bit sad to say.

 
At Friday, July 14, 2006 5:05:00 PM, Anonymous Anonymous said...

Anonymous contends that medicine is a club and I tend to agree and can offer a couple of anecdotes.

When I worked at a unversity with a medical school I often went to the hospital cafeteria for lunch. Students who were obviously in their first three years (obvious because they carried texbooks and quizzed each other) carried their trays to the dish line and sorted like everyone else, garbage here, plates ther, utensils over there.

As they enterd fourth year I would observe them siting with residents, white coats and all that. When they left they would walk up to the dishline, set down their trays, and walk away. They were being taught they were too special to be expected to carry out that fifteen second task.

I had the misforune to have a less than optimal outcome of a surgery. Somehow a laparascopic Nissen resulted in adhesions encasing my gall bladder, wrapping around my transverse colon and fastening my stomach and liver together. Three months after the Nissen I was in constant pain with acute pain several times a week and various digestive problems. I started out by returning to the surgeon but he took no responsibility for my well-being, played a game of keep-away with his residents and suggested that I had sudden onset onset IBS (what a crock) as a fifty year old male. I went to other physcians but no one would touch me.

The upshot was that a well-known physician friend talked to another equally well known physican friend who in turn talked to a third and I had a second laparoscopy in which my gall bladder and adhesions were removed. It took nine months of constant pain, frustration, and insults to my intelligence to break through the white line and get an an obvious error corrected.

I got my revenge by writing the original surgeon and telling him the outcome. He already knew from the gossip mill but I put him on notice with a registered letter. I told him I was sure he would want to know about this in order to maintain the integrity of his data base and that I would follow his future publications on the topic with interest.

I was pretty certain that his narcissism would not allow him to acknowledge a less than perfect outcome of all of his Nissens and, a number of years later, he has not published on the topic again.

My intention was to spit in his soup, I think I did, and I'm glad I did.

Getting back to the original topic, I was in the hospital for almost four days without ever laying eyes on him so it may be that one of his residents botched the surgery. Never again.

For the record, responding to me that some people form adhesions more easily than other won't cut it because I had previous and subsequent surgeries without such incidents.

 
At Friday, July 14, 2006 5:56:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous of today July 14th, I can understand your frustration and concern about your original surgeon. The surgeon is equally responsible for actions and subsequent complications associated with a resident. This is because the surgeon must be in attendance and supervising the work of the resident. I hope you also communicated what happened to the institution itself. Even published surgeons need to be watched by their superiors for their behaviors as mentors for the residents. ..Maurice.

 
At Saturday, July 15, 2006 6:49:00 AM, Anonymous Anonymous said...

In restrospect, it seems clear to me that this should have gotten back to the Human Subject Review Board. He should have reported it himself. I didn't try to go back to the institution because, having worked there a number of years and observed a good bit of physician misconduct (stalking the support staff, marrying patients, misappropriation of federal grant funds, elevating lovers without college degrees to executive positions.....), it was my observation that the institution would tolerate almost any behavior on the part fo physicians who were bringing in money.
My employment is now elsewhere, on the opposite side of the country. It has worked out much better. However, part of my decision to leave was that I was convinced that I had been maligned to the point thatI was a pariah to the local medical community. My own internist commented that he wouldn't want to be me in medical crisis at any of the local emergency rooms,as he also suspected prejudice in how my situation was handled all ver town.
Although I have physican friends and have several personal physicians whom I trust, I have become very cynical and cautious in dealing with the profession.
I'm posting anonymously because of the senstivity of the situation I described and know that several physicians walked out on a limb for me.

 

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