Wednesday, February 20, 2008

Teaching Medical Ethics (Informed Consent)

This spring I have the privilege of teaching in the required first year “Medical Ethics and Professionalism” course at Harvard Medical School. The course is taught in seminar sections. I will be working with 13 students who come to medical school with varied backgrounds and experience, but who, judging from our first class and their first weekly 500 word paper, have intelligence, enthusiasm, and idealism, in common.

Last week’s seminar focused on informed consent. They read the section on informed consent in “Principles of Biomedical Ethics” (Beauchamp & Childress) and “The Learning Curve,” a New Yorker article in which Atul Gawande discusses the tension between the patient’s wish for the best possible treatment and society’s need for training the next generation of clinicians, who have to learn by doing.

We organized the seminar around brief cases. The most gripping case involved a fourth year Harvard Medical student doing a subinternship at a local hospital. The chief resident asks the student to do a procedure s/he has never done. The procedure requires drawing blood from an artery in the wrist. The procedure, at best, is painful. The student has a good relationship with the 64 year old patient. Our question was – what does informed consent require telling the patient?

We all agreed that the student had to make sure that the patient understood the proposed procedure, the rationale for doing it, and the risks and benefits. That’s basic. But what about the fact that the student is…a student? All agreed that the patient should be told that the student is indeed a student, not a graduate physician. So far, so good.

Now came the tough question. Should the student tell the patient “this will be the first time I will be doing the procedure?” We pushed hard on this one, role playing the alternatives. I played the patient, and tried to be as difficult to handle as possible.

We took a vote on what to do. It split down the middle. All agreed that if the patient asked “have you done this before?” he should be told the truth. But the class was divided on whether this should be done proactively.

My take on this was to interpret the situation as a classical good vs. good conflict. Robust informed consent is a fundamental value. But so is competence, and we won’t have competent physicians in the future if we don’t train them now. Reasonable people, I suggested, could weigh these values differently, and come up with different answers.

But the students, happily, didn’t stop there. Without labeling it as such, they moved from clinical ethics to organizational ethics. I may have nudged them to think in terms of “preventive ethics,” but it seemed natural and sensible to them to ask – “how can we minimize the frequency of raw ethical problems like the one the student was facing?”

They came up with a number of good ideas. The hospital should have clear policies about training students to do procedures. How many should they be required to watch before trying? To the greatest extent possible, simulation should be used first. When the time comes to encourage the student to put hands on, there should be close supervision. And, there should be training, as was beginning to happen in the class, about how to talk with the patient. Students felt that in circumstances like these it would be much easier to conduct a robust process of informed consent:

“I am a medical student, working with Dr. X. I have not done this procedure before, but I have been trained in how to do it. Dr. X will be right here, to make sure everything goes right. Is all this OK with you?”

Organizations can’t be ethical without ethical clinicians. But it is much easier for clinicians to be ethical when organizations get their own ethical act together!


eric said...

Jim--Bravo! This course would have saved me years of unease. So many patients are thankful for their care and wish to return the favor to their student/doctor in some way; here is a golden opportunity. On the other hand, what about the patient who agrees out of fear of offending the student/doctor? --Eric

Jim Sabin said...

Hi Eric -

I also say "Bravo" - to Harvard Medical School for making this course part of the required curriculum.

The students shared your concern that patients might secretly feel coerced by fear. We did not have an easy answer to this, other than (a) being aware of the danger, (b) making sure that the student/doctor does not have a conflict of interest that could lead to putting too much pressure on the patient, (c) emphasizing with the patient that the choice is in her/his hands, and (d) increasing our skill at reading body language and othe cues suggesting that fear is at work.