Diagnosing ethics of medical training
Our faces were as white as our coats. It was, after all, the first time we’d be stepping from the classroom to the hospital room to examine our first real patients.
We had practiced most aspects of the physical examination on each other in class, looking in each other’s ears, noses and throats, and taking each other’s vital signs. We had even drawn our classmates’ blood, our hands trembling as we guided the sharp needles toward the moving target of rolling veins. But there were certain examinations we second-year medical students were personally spared. Our classmates would not be performing “embarrassing” rectal or pelvic exams on their reluctant colleagues.
So, on a crisp, sunny East Coast autumn afternoon, almost 30 years ago, we found ourselves at a public hospital, standing stiffly in line, gloves in hand, ready for our first field experience in practicing rectal examinations -- on two long-term comatose patients.
Our questions about the ethics of subjecting an unconscious patient to an examination were brushed aside by our faculty with the irritated reassurance that the patients would feel nothing and know nothing about our learning efforts. These patients were, after all, in the parlance of the day, GOMERs, an acronym for Get Out of My Emergency Room, used to patronizingly label the socioeconomically challenged and often unconscious victims of chronic illness or prolonged alcohol and substance abuse that sought the haven of our hospital beds.
Reluctantly, one after the other, we practiced our rectal exams -- and tried to convince ourselves that our learning procedures served to benefit our future patients and so were ethically justified.
But they weren’t. These procedures violated the basic trust between physician and patient and taught us to view those helpless and in need as objects rather than as people. It took a few years, but I relegated those teaching methods to the dustbin as soon as I left my medical training, resolving never again to interact with a patient without his or her full consent at every step. I had hoped that the evolution of medical education would have led to new approaches today for teaching students the basics of physical examinations that included a fundamental core of patient respect.
Unfortunately, a study in the February issue of the American Journal of Obstetrics and Gynecology reports that medical students are still shelving their ethics in the name of learning and, in many cases, performing practice pelvic examinations on anesthetized women without their informed consent.
The authors of the study found that 70% of the students studied before a training clerkship in obstetrics and gynecology believed that asking patients first for permission to do a pelvic examination for learning and practice was important. By the end of their clerkship, only 51% of students felt that explicit consent for the examination was needed. This erosion in patient respect occurred at the bedside, the authors said, encouraged by a “hidden curriculum” that allows students to sacrifice patient privacy rights despite policies that require explicit patient consent for student hands-on teaching.
Some educators have suggested that technology might provide a solution for student training programs. Development of a virtual reality program that enables students to practice examination and surgical techniques could potentially address the students’ learning needs without risking patient comfort, privacy or health.
But, as the authors of the study suggest, there is a less complicated solution. Faculty and administrators that oversee educational programs for medical students must make and enforce requirements for informed consent. Only if patients agree explicitly that medical students can perform, or practice, examinations and procedures should these learning opportunities be allowed. In reality, to help our future doctors, many patients are willing to permit medical students to do even uncomfortable examinations or procedures that can promote the development of the students’ skills.
As teachers of medicine, we must model not only technical expertise but also ethical behavior. The road to becoming an excellent physician requires that students learn their art and science in large part by caring for their patients. But the first step on that road for each student must begin with a simple question to the patient: “May I?”
Dr. Linda Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.