Rev. 2-14-03 Chapter IX: Ethics in Residency Training • • • • • • The priorities of residency training and patient care • The tension between the need to gain experience and the welfare of patients • The tension between the demand to be taken seriously as a professional and the demand to be honest about one’s inexperience • Disclosure of inexperience and informed consent • Determining the appropriate balance between training needs and patient care • 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. Rev. 2-14-03 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 Rev. 2-14-03 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 Rev. 2-14-03 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, Rev. 2-14-03 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 Rev. 2-14-03 impaired physician. Several questions are raised by situations in which a resident suspects his superior is impaired: • what is meant by an impairment? what kind of impairment is involved in each case? • how does the impairment affect job performance? • is the inappropriate behavior a one-time occurrence or is it part of a pattern that is repeated over time? • what mechanisms are available for addressing the problem? • what are the personal consequences for the junior physician if he informs on his superior? • 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 Rev. 2-14-03 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: • support residents in voicing their medical, ethical, and legal concerns without fear of ostracism or ridicule; • ensure that effective mechanisms for questioning the authority of one’s superiors are available; • provide confidential forums for reporting concerns about impaired physicians; • 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; • establish procedures and policies that meet the educational needs of residents without endangering the welfare of patients; and • 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. Rev. 2-14-03 Wazana A. “Physicians and the pharmaceutical industry: Is a gift ever just a gift?,” JAMA 2000; 283:373-380.