Chapter IX: Ethics in Residency Training and Beyond

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Chapter IX: Ethics in Residency Training
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The priorities of residency training and patient care
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The tension between the need to gain experience and the welfare of
patients
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The tension between the demand to be taken seriously as a professional
and the demand to be honest about one’s inexperience
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Disclosure of inexperience and informed consent
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Determining the appropriate balance between training needs and patient
care
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Voicing concerns
Balancing the needs of patients and residents: the debate over residents’ work hours
Challenging authority
Whistle-blowing and the impaired physician
Conflicts of interest: interactions with drug and device companies
Institutional responsibilities
Case 1: At 4:00 am a young Latin-American male who had just been stabbed in the chest came
to the Emergency Department with a pneumothorax. The ER physician contacted the attending
thoracic surgeon, who instructed the ER physician to call the surgical team. At this time of the
night, the surgical team consisted of the resident, Dr. P. He was to examine the patient, work
him up, put in a chest tube, follow him and discharge him as he saw fit.
Dr. P had not inserted a chest tube in a long time and felt uncomfortable doing so without
supervision by an attending physician. On the other hand, he was aware that he was expected to
be able to do the procedure and that if he told the ER physician that he did not feel comfortable
doing it, his standing as a professional would suffer.
What should Dr. P do under the circumstances? How should a resident’s lack of experience
influence his or her decision about performing procedures when asked to do so? Is it ever
appropriate to refuse to perform procedures one does not feel comfortable doing?
Case 2: Dr. S is a senior fellow under the supervision of Dr. M. The patient, Mr. W, had been
hospitalized 4 days earlier after several unsuccessful attempts to diagnose his mysterious set of
symptoms. Dr. M now decided to do a liver biopsy. She explained all the reasons for doing the
procedure, emphasized that it could provide helpful information, and also described possible
complications. She also described the various alternatives that were available and the
advantages and disadvantages of each, but said they were unlikely to provide as useful
information as the biopsy.
Having confidence in Dr. M’s clinical judgment, Mr. W agreed to the procedure. At that point
Dr. M told Dr. S that she would like him to do the biopsy. She informed Mr. W that she would be
present during the biopsy and he gave consent. However, Dr. M did not tell Mr. W that this was
Dr. S’s first time doing the procedure, nor did Mr. W tell inquire about his previous experience.
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Has informed consent been obtained from Mr. W? Is it appropriate to inform patients when a
procedure is being done for the first time? Is it reasonable to presume that patients implicitly
consent to being treated by doctors in training in a teaching hospital?
I.
Priorities of residency training and patient care
A. The tension between the need to gain experience and the welfare of patients
As in any field, there comes a time when physicians in training must begin to practice the theory
they have been taught and the procedures they have only watched their mentors perform. In the
early stages of clinical training, it is natural for the younger physician to feel discomfort and
some degree of self-doubt. To a large extent, this discomfort comes from the realization that their
inexperience has the potential to harm the patients they are treating, although with adequate
supervision the potential for harm may be significantly reduced. However, it is essential for
physicians to gain experience if they are ever to learn the techniques and practical skills they will
need to provide good patient care.
To some extent, current patients are being used as objects of medical learning so that, in the
future, their physicians will become skilled professionals. In other words, to be sure of future
experienced physicians, current patients have to be subjected to the less-practiced hands of
residents.
B. The tension between the demand to be taken seriously as a professional and the demand
to be honest about one’s inexperience
In order to be able to learn, physicians in training have to acknowledge and accept the limits of
their knowledge and skill without fear or embarrassment, and ask for instruction from those who
are more experienced. At the same time, however, they do not want to come across as insecure or
inept. They want to be taken seriously by others on the medical team, to be thought competent
and self-confident. There is an understandable reluctance for physicians in training to admit their
inexperience and self-doubt, but it is essential to the educational process that they do so.
Case 1 illustrates these tensions. Here Dr. P is the only member of the surgical team on call and
the insertion of the chest tube is an emergency procedure. In such a situation, the patient’s
medical condition may require the resident to act, despite his discomfort and self-doubt.
However, the lack of adequate supervision for the resident is a systemic problem that needs to be
addressed on the institutional level.
C. Disclosure of inexperience and informed consent
The doctrine of informed consent requires that physicians provide their patients with information
that a reasonable patient would want, under the circumstances, about the proposed medical
treatment and its risk, benefits, and alternatives. When a procedure is to be done by a physician
with little experience doing it, the question is whether a reasonable person would want to know
this in order to make an informed decision, that is, whether this information would be materially
relevant to the patient’s decision to consent. If so, the failure to disclose this information would
be a breach of the physician’s duty to adequately inform the patient. Even if the patient would
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have consented to the procedure if the information had been disclosed, the failure to disclose it
nonetheless constitutes a breach of the physician’s fiduciary duty.
Disclosure of the physician’s level of experience may lead the patient to decline to have a
procedure performed by an inexperienced physician. This may happen, but also may not,
especially if the patient is informed that the risks and complications of the procedure may
actually be less in a teaching hospital than in a community hospital. The risk of having a
procedure performed by a resident supervised by an experienced attending physician may be less
than when the procedure is performed by a private practitioner who only does it occasionally.
D. Determining the appropriate balance between training needs and patient care
If patients were given a choice between having a procedure done by a skilled physician and
having it done by a less experienced resident, many would probably choose the former.
However, if patients were given the freedom to choose in all cases, no physician in training
would ever gain the experience needed to become a skilled professional. Future patients depend
on the services of skilled professionals, just as current patients depend on the services of skilled
professionals who themselves underwent a period of training in the past. On a utilitarian analysis,
which aims at the greatest well-being of the greatest number of patients in the present and the
future, physicians must be permitted to practice on current patients in order to enhance their
knowledge and perfect their skills.
However, the utilitarian justification must be balanced against other bioethical principles, in
particular, the principle of non-maleficence, “do no harm,” and the principle of respect for
patient autonomy. Physician training should not be at the expense of patient well-being. Among
other things, physicians in training should guard against an exaggerated sense of competence that
can place the patient in jeopardy. To protect the patient, their mentors should encourage them to
voice their feelings and opinions and to admit their discomfort in performing new procedures.
This encouragement is also a necessary part of the educational process.
Lack of experience also has implications for the informed consent process. Most of us have little
difficulty agreeing that information about the relative inexperience of one’s physician to perform
the particular procedure at issue is relevant to our decision to have it. Moreover, the fact that a
procedure is being performed at a teaching hospital does not affect this analysis significantly.
Patients admitted to teaching hospitals generally do not understand that they will be the subject
of trial and error by interns and residents, and the supposition that they have provided a general
consent to being used for teaching purposes is highly suspect. At any rate, a general consent does
not translate into specific consent for particular procedures.
Teaching hospitals may assert that they could not fulfill their mission of training future
physicians if inexperienced physicians were not permitted relatively unrestricted access to
patients. However, while it is true that teaching hospitals have several goals, including education
and research, their primary mission is the care of patients.
It is sometimes said that indigent patients, who are often treated at teaching hospitals, do not
have the option of choosing to be treated by an experienced attending physician rather than a less
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experienced resident. However, this is a problem with our increasingly two-tiered health care
system and does not alter the physician’s obligation to obtain informed consent.
As part of the informed consent process, the patient should not only be made aware that he or she
is being treated by a resident, not an attending physician, but also of the additional support,
teaching, and supervision that are used to ensure that the procedure is done correctly. Informed
of these benefits, most patients are likely to consent to the arrangement.
E. Voicing concerns
Residents who feel uncomfortable performing a procedure for which they have little experience
should recognize that they are more than passive participants in a process of medical training.
They are moral actors, and they have the right and responsibility to raise concerns and voice their
feelings when confronted with situations that they feel inadequately equipped to handle. For
example, it may be appropriate for a resident to refuse to do a procedure he is asked to do by a
senior physician unless the resident has adequate, on-site supervision.
II.
Balancing the needs of patients and residents: the debate over residents’ work
hours
As of July 1, 2003, the system of training resident physicians in the United States will undergo
substantial changes. More, but not all, residents will be limited to 80 hours of work per week,
averaged over a four week period, as per a new requirement by the Accreditation Council for
Graduate Medical Education.[Leape and Epstein; Steinbrook]
Proponents of these changes argue that limitations are necessary to ensure the physical and
mental health of trainees and to reduce errors that result from fatigue and loss of sleep. That is,
both the needs of patients and the needs of trainees are furthered by shorter work hours. Critics,
on the other hand, worry that shorter work hours will deprive trainees of opportunities to see a
clinical encounter evolve and will require more frequent handoffs of care to other doctors, which
may cause additional mishaps. Concern has also been voiced about the impact of shorter work
hours on the inculcation of accountability and professionalism in the trainee.
Reduction in working hours alone is not likely to significantly improve medical training or
patient safety. In addition, handoffs must be made safer and, more important, strategies for
inculcating accountability and professionalism need to be explored.
III.
Challenging authority
Case 3: Dr. M, a resident at a large teaching hospital, established what he believed was a
trusting relationship with an elderly man who had no family. He confided in Dr. M that he feared
he had cancer, mistrusted the doctors to tell him the truth, and asked Dr. M to “level with him”
whatever the results of the tests he was undergoing. The lab tests confirmed terminal cancer and
that he probably had a very limited time to live. Dr. M wanted to go to the patient directly and
tell him the prognosis, but his attending said that to do so would cause him undue harm. He said
such a delicate situation required a more experienced approach and that he, the attending,
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would handle it.
The chain of command in medicine is not an arbitrary set of restraints, but can be justified on the
grounds of increased efficiency and responsibility. In the medical hierarchy, attending physicians
generally have more decision-making authority than residents do, and residents have more than
medical students. Allowing the chain of command to be disrupted whenever residents or students
feel they have a better idea could jeopardize the welfare of patients. In addition, there are
situations in which the need for rapid intervention precludes extensive discussion about the
wisdom of following the supervisor’s orders. However, there are circumstances in which the
authority and directives of the senior physician ought to be questioned. The decision to withhold
the cancer diagnosis from the patient in case 3 may be just such a situation.
The situations that may lead residents to question the authority of their superiors cover a wide
range. They include ones in which the resident observes or is asked to participate in substandard
care, as judged from a medical point of view. For example, the resident may be asked to
participate in a procedure that causes the patient unnecessary pain or a risky unorthodox
procedure for which there is scant supporting evidence in the literature. They may also include
situations in which the resident observes or is asked to participate in medical treatment that is
questionable from a legal and/or ethical point of view. For example, the resident may be asked to
assist in surgery on a patient from whom, in the opinion of the resident, adequate informed
consent has not been obtained.
Conflicts between the orders or actions of a superior in the medical hierarchy and the action
which the junior member of the team believes is best for the patient and/or morally required can
be dealt with in different ways. The least satisfactory is simply to go along with the superior’s
orders and suppress one’s misgivings. When possible, the resident should share his concerns
with the supervisor, preferably in a non-confrontational manner. In more extreme situations,
when the resident is convinced that his superior is asking him to participate in something that is
medically, ethically, or legally inappropriate, the resident may need to defy the authority of his
superior. Whatever decision is made, the resident should realize that he is responsible for his
own actions and that he cannot completely shift the burden of responsibility to his medical
superiors.
IV.
Whistle-blowing and the impaired physician
Case 4: As a resident in anesthesiology, Dr. A was assigned for the first few months to an
attending who would be his direct supervisor. Dr. A learned a lot from his attending. Sometimes,
however, Dr. A thought she acted oddly. For example, he would find her sitting with her legs
crossed in an awkward position and she would jump up quickly when she saw him. Once when a
drug was not accounted for she said “I gave it to a patient, but forgot to enter it into the chart.”
Dr. A had a vague sense of unease about the missing drugs, and was unsure what to do.
Self-regulation is an essential element of the profession of medicine. This regulation requires
monitoring not only of oneself but also of one’s professional colleagues, a responsibility that is
primarily rooted in the obligation to prevent serious foreseeable harm to patients. One important
aspect of this self-regulation is the creation of effective mechanisms for dealing with the
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impaired physician.
Several questions are raised by situations in which a resident suspects his superior is impaired:
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what is meant by an impairment? what kind of impairment is involved in each case?
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how does the impairment affect job performance?
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is the inappropriate behavior a one-time occurrence or is it part of a pattern that is
repeated over time?
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what mechanisms are available for addressing the problem?
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what are the personal consequences for the junior physician if he informs on his
superior?
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what are the consequences for the physician who is informed on?
Whistle blowers are individuals who inform on behavior believed to be unprofessional,
unethical, or illegal. When a resident is confronted with an attending physician who is unable to
fulfill his responsibilities as a result of physical or emotional impairment, the resident should
report his findings to a supervisor, either the chief resident or the chief of the clinical department.
At the same time, assistance and support should be offered to the one against whom the
allegations are made, and his rights to due process and privacy should be protected. [Glazer and
Glazer]
V.
Conflicts of interest: interactions with drug and device companies
A conflict of interest arises when a professional’s personal or financial interests conflict with the
interests of those who place their trust in the professional. In these cases, elevating the
professional’s interests over those of the parties in positions of reliance compromises or
detrimentally influences professional judgement and undermines trust. Conflicts of interest raise
ethical concerns because of their potential to cause harm if they influence action in appropriate
ways.
One area that is especially prone to conflicts of interest is staff interactions with drug and device
companies. As every resident knows, gift giving from drug and device companies to physicians
is widespread. In a survey of chief residents of emergency medicine programs in the U.S.,
Reeder and colleagues found that pharmaceutical companies distributed gifts in at least 90 per
cent of responding programs [Reeder] Studies have also shown that interactions with drug and
device company representatives, which begin in medical school and continue through residency
training and subsequent practice, have a definite influence on the prescribing decisions of
physicians, although most physicians claim to be immune to such influence. [Wazana;
McCormick et al; nofreelunch.org]
Individual health professionals should be particularly attentive to ways in which their behavior
may be inappropriately influenced by a conflict of interest and should avoid placing themselves
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in such situations whenever possible.
VI.
Institutional responsibilities
The education and training of future physicians is not merely the responsibility of individual
senior physicians, it also an institutional responsibility. As such, institutions have an obligation
to create an organizational climate in which residents are able to function as moral actors and
take responsibility for their actions. In particular, health care institutions have a responsibility to:
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support residents in voicing their medical, ethical, and legal concerns without fear of
ostracism or ridicule;
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ensure that effective mechanisms for questioning the authority of one’s superiors are
available;
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provide confidential forums for reporting concerns about impaired physicians;
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arrange incentives in such a way that whistle-blowers come to be seen not as enemies
from within but as valued friends of the institution;
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establish procedures and policies that meet the educational needs of residents without
endangering the welfare of patients; and
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create and support staff use of appropriate forums to which questions and concerns
about conflicts of interest can be brought.
References
Glazer MP, Glazer PM, The Whistleblowers: Exposing Corruption in Government and Industry.
New York: Basic Books, 19890.
Kushner T, Thomasma D, eds. Ward Ethics. Cambridge: Cambridge University Press, 2001.
Leape L, Epstein A. “Rethinking medical training - the critical work ahead,” New England
Journal of Mededicine 2002;347;16:1271-73.
McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS.” Effect of restricting contact
between pharmaceutical company representatives and internal medicine residents on posttraining
attitudes and behavior,” JAMA 2001;286:1994-99.
Reeder M, Dougherty J, L.Whiter LJ. “Pharmaceutical representatives and emergency medicine
residents: a national survey,” Ann Emerg Med 1993; 22:1593-6
Steinbrook.R. “The debate over residents’ work hours,” New England Journal of Medicine 2002;
347;16:1296-1302.
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Wazana A. “Physicians and the pharmaceutical industry: Is a gift ever just a gift?,” JAMA 2000;
283:373-380.
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