Bioethics Discussion Blog: Patient Informed Consent for the Teaching Hospital "Trainee" Care: Informing Realistic Scenarios

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Monday, September 16, 2013

Patient Informed Consent for the Teaching Hospital "Trainee" Care: Informing Realistic Scenarios




The following article I wrote for Bioethics.net is reproduced here with permission


09/16/2013

PATIENT INFORMED CONSENT FOR THE TEACHING HOSPITAL “TRAINEE” CARE: INFORMING REALISTIC SCENARIOS

by Maurice Bernstein MD
Informed consent is the ethical and legal hallmark for the support of patient decision-making in medicine.  Though the ethics of patient communication of facts without deceit has been part of medical consideration for generations, it wasn’t until the landmark decision Schloendorff v The Society of the New York Hospital in 1914 that informed consent became United States law.  Informed consent has been also been emphasized from the aspect of medical ethics, in recent decades, as decision making has moved from physician paternalism to patient autonomy.  Patients awaiting medical/surgical procedures are currently given variable content and amounts of information about their illness and the procedure itself and the risks and outcomes anticipated. Some general information is provided as a printed form and patient specific details is provided directly to the patient or surrogate by a healthcare provider, hopefully one who is a participant in the procedure.
The matter of  the patient being fully informed as to the upcoming procedure may be complicated in teaching hospitals where,  in addition to the attending physician and surgeon,  fellows, residents, interns and medical students may be present during the procedure  and actually may participate to varying degrees as part of formal training exercise. How much detail regarding this possible array of “learners” and what duties they will carry out that  is withheld or actually given to the patient as part of the informed consent procedure is unknown but possibly minimal if even presented at all.
A study published in the Archives of Surgery, January 2012 by Porta, et al reports responses of 316 patients preparing for surgery within a teaching hospital of the U.S. Military Health Care System, surveyed regarding their opinion with respect to being personally attended by trainees. “…most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure … However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent.”
One realistic scenario that could have been presented to those study patients would have involved their awareness that a subtle or at times not too subtle dilemma develops for those who teach the trainees in teaching hospitals. A description of that very personal dilemma of teaching to a trainee a medical procedure on a patient with its opposing risks vs benefits to both is beautifully presented in the “In Practice” column of the July-August 2013 issue of the Hastings Center Report titled “Patient and Trainee: Learning When to Step In”  by Christy L Cummings.  The goal is to provide the opportunity for the trainee, primarily an intern or resident or even a fellow physician, to adequately learn a procedure with supervision on a patient so that in the future that physician will be able to repeat the procedure on their patients effectively and safely.  The goal of both the teacher and trainee is, at the time, similarly, to complete the procedure effectively and safely.   This opportunity, despite the teacher observing and communicating with the trainee, nevertheless has with it the uncertainty of a procedure gone wrong, not completed and the patient about to be worse off. This was the case as Dr. Cummings was observing her trainee unsuccessfully attempt to insert an endotracheal tube into a  premature baby who was at first stable but then with repeated attempts the baby’s condition deteriorated. So, if difficulties appear both in the task itself and the condition of the patient, a new uncertainty arises for the teacher. When should she intervene, put her “hands on”, taking over the task of performing the procedure and remedying any serious problems with the patient’s condition?  If she intervenes too quickly,  the trainee may miss a valuable opportunity to personally handle, with the teacher’s advice, a difficult situation and complication thus learning for the care of future patients.  On the other hand, it is the teacher’s responsibility to attend to the safety of the patient and the completion of the goal of the procedure.  When should the teacher take over?
This dilemma is not at all rare and, as such, one could reasonably ask whether these uncertainties should also be part of the information provided to the patient in a teaching hospital for truly informed consent.  And If not, why not?

5 Comments:

At Monday, September 16, 2013 6:01:00 PM, Blogger Maurice Bernstein, M.D. said...

For more on the topic of the ethics of patient care by "trainees" in teaching hospitals go to this link:
Sethuraman K R. Ethics of patient care by trainee-doctors in teaching hospitals. J Postgrad Med [serial online] 2003 [cited 2013 Sep 16];49:159 ..Maurice.

 
At Tuesday, September 17, 2013 1:05:00 PM, Anonymous Anonymous said...

Thank you for this post and the issues it raises. I was in a very large well respected teaching hospital many years ago. At that time, I had serious reservations about being provided care by any medical students, nursing students, interns or residents. I had a private physician with privileges at that hospital who was supposed to do my outpatient gynecological surgery. While in her office, prior to the surgery, I expressed my concerns. She gave me her likely standard speech about the fact it is a teaching hospital, they provide the best care, everyone is supervised etc. I arrived for my surgery to find a male gynecologist listed as my doctor. I was not comfortable with this, but I was very young and very nervous and just asked when my doctor would be there. She arrived less than five minutes before my surgery and I did not see her again until my follow up appointment. I ordered my medical records and found out later the male gyn had done a pelvic exam once I was under anesthesia. This was despite the fact I had already had multiple ultrasounds and a pelvic exam done by my own doctor less than 5 days before. It was also the resident that had dictated the operative report, noting that my doctor was "present" during the surgery and it was this resident whose name was on the post-op orders when I developed complications. While in recovery, I continued to suffer pain and other issues, unaided by any nurse or my own doctor. After discharge, I was then forced to return to the ER later that day and treated for complications. I was told I would have simple quick outpatient surgery, but my records show I was in the OR for 2.5 hours, just to have a laparoscopic ovarian cyst removal. I shudder to think what went on in that 2.5 hours. I now have cysts on my other ovary and I am completely terrified of having the surgery. The pain, the ENDLESS protracted nausea and vomiting, excessive bleeding, urinary retention and subsequent bladder/kidney infection and the other complications are all I can think of. I feel that I was lied to and when I asked that it be my doctor who did the surgery, my wishes were ignored and I had medical complications as a result. I am reluctant, almost refusing any surgery to treat my current health issue because I am simply too paralyzed with fear, anger, humiliation, panic and other emotions to set foot in any hospital, teaching or otherwise. I do not know what the answer is to the question posed in your post, but I know that misleading a patient and allowing things to happen the patient stated emphatically that there was no consent to are not the answer. If that is the only way doctors can be trained, then there needs to be a systemic change.

 
At Tuesday, September 17, 2013 1:31:00 PM, Anonymous Anonymous said...

Hello: I just left a comment regarding my negative experience in a teaching hospital following gyn surgery. I failed to follow instructions. Here is my pseudonym, "Patient X".

 
At Tuesday, September 17, 2013 6:37:00 PM, Anonymous Anonymous said...

I think that, at most, these facilities should be required to make it clear that they are teaching hospitals. If they're upfront about that, it's generally understood that students and residents will be participating in care. If I'm a patient going into a teaching hospital, I personally would rather forego any superfluous red tape and paperwork. I also don't want the higher medical costs that come with an overly bureaucratized system. All I expect is honest answers if I have any questions or concerns about who will be giving care and accountability if something goes wrong.

Telling me that a resident might do work on me at a university hospital is like telling me that a teenager might be making my Big Mac at McDonalds. Either situation could possibly involve me getting a preventable illness, but I generally trust that the system has enough checks and balances in place to prevent that from happening and I understand that this is how things have to work in a world where veterans leaving an industry have to be replaced by a younger cohort.

My 2 cents.

--RDW

 
At Wednesday, September 18, 2013 2:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Checks and balances are important safety measures for sure..but, unfortunately there are situations occurring in clinical procedural teaching which strain or defy these attempted safeguards. It is because each same scenario has two non-standard variables, the "learner's" and the patient's actions and reactions. That is why a procedure in by an established practitioner may have negligible risk, the same procedure performed by a "learner" despite supervision may be more risky and this difference should be relayed without dilution to the patient for consideration. ..Maurice.

 

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