Duty to Learn vs. Duty to Treat: The Medical Student’s
Professional Responsibility
Marci Turner, Claire Jones, Megan Acsai, Dustin Costescu, Sara Puente, Tania Wilson,
Medical Students, University of Western Ontario, London.
As medical students gradually assume more clinical roles throughout medical school,
they are not only responsible for their education, but also for patient health and wellbeing. Since medical students are learning through first hand experience as the most
junior members of a medical team, there is an expectation that mistakes will occur,
which, while in and of themselves are an important aspect of learning, may place the
patient’s best care at risk. Identifying this ethical dilemma as medical students ourselves,
we performed a study to explore the interplay of the medical student’s two roles: the role
of student learner and health care provider. Research has been performed by ethicists and
medical educators on the topic of the ethical conflicts challenging medical students;
however, the student perspective is lacking on the issues faced as a medical student enters
clinical practice and challenges the balance between his duty to learn and to treat.
For our study, upper year medical students at the Schulich School of Medicine &
Dentistry at the University of Western Ontario were invited by email to submit narratives
of experiences in which they felt a conflict existed between their roles of student and
member of the health care team. The responses were analyzed qualitatively using line-byline coding by student investigators who then triangulated their findings to develop
themes.
Many of the ethical dilemmas involved direct conflicts between students and patients. A
theme that rapidly emerged was the ethical concern involved in obtaining consent for
student participation in patient care and patient involvement in student education. Such
situations often involved a patient confronting a student about his level of competency
while the student was obtaining consent for an invasive procedure. Other scenarios arose
in which no consent was obtained for student involvement in patient care, many of which
involved patients under anesthesia. Students also identified concerns about confidentiality
limiting learning and highlighted instances where a health care professional privileged to
a patient’s confidential information would overlook patient privacy to afford a student a
learning opportunity.
Another theme identified was competency in patient care. These submissions explored
the struggle to balance a student’s true abilities in providing patient care with those
perceived by his preceptor, the patient and the student himself. Many students question
their competency in providing high quality patient care while learning new technical
procedures. Additionally, students felt conflicted in terms of patient objectification for
learning. Highlighted situations included ones in which student involvement in patient
care risked the patient’s dignity, comfort or convenience, in spite of the patient
consenting to student participation, or when patients would not directly benefit from
student learning involving their case.
Students also recognized conflicts with the institution of medicine or medical team,
centered on themes of role resistance and submission to the student role. Many student
submissions featured scenarios in which they described feeling uneasy about assuming
the tasks assigned to them by their supervisors. Similarly, it was common among the
narratives for a student to suppress his own opinions about patient care and medical
management, rather than question an authority figure.
When faced with such ethical conflicts, students must react appropriately or risk excusing
unethical practice in the future; research has shown that the majority of medical students
subconsciously undergo changes in their personal codes of ethics (Satterwhite 2000,
Goldie 2004). Thus we believe that medical schools have an obligation to ensure that
clinical instructors are aware of moral teaching practice guidelines that relate to specific
ethical challenges faced by medical students, specifically those in which their
professional responsibility is in conflict – where the duty to learn and the duty to treat
diverge.
References
Goldie, J.G.S. (2004) The detrimental ethical shift toward cynicism: Can medical
educators prevent it? Medical Education, 38, pp. 232-238.
Satterwhite, R.C., Satterwhite III, W.M. & Enarson, C. (2000) An ethical paradox: The
effect of unethical conduct on medical students’ values, Journal of Medical Ethics, 26,
pp. 462-465.
Key words
medical student ethical dilemmas, hidden curriculum