The ethics of trainee-patient encounters: Are we practicing on the poor?

I performed my first paracentesis in November of my intern year.  It was 3 a.m., and I was on overnight call in a packed ICU.  The patient, a 45-year-old male with hepatic encephalopathy, was hardly alert enough to remember my name.  He didn’t know I was an intern.  He didn’t know I’d never even attempted a paracentesis before.

After I finished, I added the patient’s name to my procedure card.  I hurried to get an ABG on his neighbor.  I placed an NG tube in a GI bleeder. My senior resident and I never even wondered if our patient had a right to know how green I was.

Months later, at a meeting with residents and faculty in my internal medicine residency program, the discussion turned towards the ethics of residency training at teaching hospitals.  The idea that trainees treat patients who may have little to no understanding of what it means to be a “resident physician” can be morally unsettling.  The medical profession has traditionally overcome this by accepting a level of deception by omission for the sake of physician training.  Patients are our teachers — whether they realize it or not.  By submitting their trust to our profession they provide trainees with an invaluable service: The practice needed to become strong clinicians.

But who exactly are we practicing on? A study in the Journal of Family Medicine found that patients of resident physicians in an ambulatory care setting were younger, more likely to be non-white, and more likely to be reimbursed by Medicaid.   The Journal of Academic Medicine recently reported that minority patients were over twice as likely as white patients to be admitted to teaching hospitals.  This data begs an unsettling question.  Are we, as one resident asked at our recent meeting, practicing on the poor?

At the cornerstone institution of my internal medicine residency program, a New York City safety-net hospital, we treat an overwhelmingly low-income, homeless, and minority population.  As residents we pride ourselves on the level of autonomy we have in directing patient care: attendings’ roles are supportive, not managerial.  But the fact remains that we are not fully trained physicians, and the proportion of patients who truly understand this is unclear.

This leads one to wonder if care delivered by trainees, under the supervision of attending physicians, is sub-par.  The answer, according to the literature, is probably not.  In fact, the body of evidence on the matter suggests that quality of care at academic teaching hospitals is likely superior to that at hospitals without trainees.  A recent study in Medical Care found a 10% relative reduction in the adjusted odds of mortality from myocardial infarction, heart failure, and pneumonia for patients admitted to teaching hospitals when compared to non-teaching hospitals.

Data such as this reshapes the question of whether we are, in fact, practicing on the poor. Considering the evidence that care delivered by trainees is just as good — if not better — than that delivered at a non-teaching hospitals, one faculty member at our meeting mused, “if we are indeed practicing on the poor — lucky them.”

Nicole Van Groningen is an internal medicine resident.

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  • Ed

    I think it’s telling that physicians in training almost universally defend this 19th century paternalistic practice. You’re willing to take advantage of those least able to object (due to ignorance and/or lacking insurance) instead supporting real financial incentives and true informed consent, especially considering the near universal acceptance by your profession of basic medical ethics such as patient autonomy and first, due to harm.

    I get, as the vast majority of patients do, that physicians need hands on training to become competent doctors. In the future, I intend to consent to their participation, depending on the nature of the procedure, its complexity, the actual level of “student” participation and experience, and whether my consent was solicited in the first place. Just to be clear, the fine print on the myriad admission documents we’re expected to sign upon admission, doesn’t remotely meet my, nor many patients I suspect, definition of informed consent. Depending on the nature of the illness, I doubt many teaching hospitals will turn patients away, considering the potential liability, because a patient declined a student performing their first hands on procedure.

    • ninguem

      “…..Depending on the nature of the illness, I doubt many teaching hospitals will turn patients away, considering the potential liability, because a patient declined a student performing their first hands on procedure……”

      Mine did. Yuppies came in, wanting the perceived excellence that came from the University, without involvement of the very trainees that makes the University excellent. Faculty only.

      They were told, flat-out, no.

      And I mean, when I was faculty, I told such yuppies, flat-out, no, on direct order from my department chair. On at least one occasion, the yuppie had to hear it from the Department Chairman personally.

      • Ed

        Once in the door, your hospital can’t turn anyone away without arranging for alternative care somewhere else first. And that’s essentially the rub isn’t it because what other facilities will accept patients without insurance?

        • ninguem

          The cases I was describing were elective procedures. So yes, they could be turned away.

          An emergency patient, or otherwise already in the hospital, refusing the residents constantly, I don’t know what would be done.

          I do know I have had patients at University, in my training days, kept repeating the mantra “I want a BOARD-CERTIFIED physician”, which wasn’t me, as I was in training.

          MANY TIMES when this happened, the physician coverage changed from a highly experienced senior resident, fellow, or new faculty that hadn’t had time to take boards……that person was pulled off, and some older faculty, actually LESS experienced…….or let’s say outdated and out-of-practice, in office or lab as researcher or administrator……..was substituted.

          The patients actually increased their risk rather than decreasing it, by asking that the system run in a way it does not normally run.

          But hey, I wouldn’t like the doc doing his/her first procedure on me. Then again, I don’t know the full story. Maybe that person did ten under supervision perfectly, and this is the first one completely solo with the senior doc across the hall, I don’t know.

          • Suzi Q 38

            It is worth it to ask.
            Do you want the fellow doing your important surgery, or do you want the physician?
            I didn’t want the resident to do my LP.
            In a true emergency, I would take anyone, including the nurse.

          • querywoman

            Sometimes the young ‘uns know more; sometimes they don’t.
            In my experienced teaching training doc’s office, I just about got the old guy trained to quit blaming my eczema lesions on picking and/or scratching it.

            The rezzidents come in and say scratching at it caused it.
            I shot one down recently, in front of the senior man, by saying, “That doesn’t explain what caused it in the first place.
            The physician emeritus agreed with me.
            As the layers peel off, I’m getting an idea of how it formed. A very painful bizarre patch that I had in my twenties resurfaced last year. I told him that I have learned that this stuff didn’t go away, that more tissue formed around it to cushion it.
            I remain optimistic. My sharp eyes and mind evaluate the young ‘uns. I am always looking the right rezzident to take up the cause of my brand of atopic eczema. I plan on training him or her real good!

    • buzzkillerjsmith

      Ho hum.

      Most patients, rich and poor, at the county or at Cedars Sinai, absolutely love being seen by med students and residents in addition to being seen by the attending physician. Those who refuse are of no consequence to medical training. They will not be missed.

      And as Dr. G. notes, the care even at county is very good.

      Next case.

      • ninguem

        ^^^ what buzzkiller said ^^^

      • JR DNR

        When I was at the ER in a teaching hospital, I had no clue it was a teaching hospital. No one ever told me. It was a horrible facility all around.

    • A Banterings

      Ed,

      I could not agree with you more. I thing a good (yet extreme) example is Tuskegee…

  • A Banterings

    The first question is: (as Bates Guide says) do you introduce yourself as a student/resident/etc., get the patient’s consent (and honor it). That would dictate whether the encounter was ethical or not.

    If you say nothing other than you are Dr. Such-n-such, and rely on the consent form they signed, then I question the ethics of the entire encounter regardless of income status,

    This is the same quandary and ethical dilemma of check cashing businesses; is it better to give the poor substandard service or no service at all?

    Note: I am not saying residents or teaching hospitals provide substandard service, but the author makes that implication saying “if our patient had a right to know how green I was.” If you are not comfortable with that term, then you could say “charged additional fees normally not charged” in this case be an instrument of learning.

    To ensure that these encounters ARE ethical, you would need to ensure that the patient will still receive the same standard of care if he refuses to be treated by students, not be videoed or photographed, participate in any research, etc. There can not be any coercion (implied or explicit) either.

    Remember ethics is about doing the right, just, and moral thing, which is different from doing what is legal. Ethics is about “doing to others as you would have done to you.”

    This also shows a prejudice. These are “poor” patients, not just patients. I thought physicians did not judge us. Would you be comfortable if they were identified by ethnicity? What if the article was titled, “The ethics of trainee-patient encounters: Are we practicing on the Latino/Russian/African-Americian/Caucasian Male population?”

    Ethically this question should be about ALL patients, not just low income patients.

  • Suzi Q 38

    Having had my hysterectomy done at a cancer teaching hospital, I was introduced to medical students and interns/residents/fellows.
    They would come in in a small group, with my doctor holding “court.”
    My guess is that he would describe my condition before they entered the room. Once in, no one asked me questions about my condition, except my doctor. I didn’t mind at all.

    One time I did mind. I wanted to get angry with my doctor, and this intrusion was a missed opportunity to vent at him. I couldn’t do that in front of his students.

    I did mind when I needed a lumbar puncture to be done and I had accidentally taken aspirin the night before. The doctor voiced his concern about that, but I explained to him that no one had called me before my procedure appointment because they neglected to schedule me at all. Since I had the appointment card as proof that I was told to come and have my LP, I arrived at the given time, expecting such.
    This caused them to scramble for a physician to do this. When the doctor came in to see me, he was going to do the lumbar puncture anyway, in spite of my having taken the aspirin. I told him that I needed to see proof that this was O.K., given that his first impression was that it might not be O.K. I needed to see a study…anyway, he found one, I read it and figured that it was O.K., LOL. I then asked him if he was a student. He said “no.”
    He did say that the students do a very good job and are watched closely.

    I told him that would be fine for other things, but not for my lumbar puncture today, thank you.

    • querywoman

      Teaching hospitals love hysterectomies! A certain amount are necessary for board certification. I’ve used my nearby public teaching hospital in the past, and had whole armies come in.
      I don’t know how I really felt about it. I don’t like doctors picking my priorities on what to tell the trainees.
      As an aside, once I had a horrid bleeding, pus-filled in areas, hard-edged abcess in my armpit. I told about 6 people in the public dermatology clinic that it didn’t really hurt, and their eyes all got very wide.
      My current derm is associated with a church hospital that also trains residents and medical students. They all seem to like his rotation. Sometimes there are four people in the room, sometimes not. One of his staff, who might be unlicensed, always acts as scribe, entering his info in the computer. A medical assistant or LVN might wrap my legs or give me an injection.
      I have seen his PA sometimes since when I started seeing him. I don’t know exactly what their relationship is, but she’s been known to pop in when I’m with him. He told me he asks her stuff sometimes.
      I never feel like cattle in his office.

  • ninguem

    Uh……..does anyone have an alternative suggestion?

    Because the only alternative that comes to my mind, is they don’t get any care at all.

    OK, maybe patient should have been told how green you were. To what end? Insist on faculty?

    Faculty dragged in every night for one such patient after another.
    There will be no faculty within a year.

    • Ed

      Yes, practice ethical medicine by truly soliciting informed consent in advance each and every time instead of treating patients like cattle and sweeping this under the rug. Explain who you are and your actual level of experience doing this or that. Some patients will decline but most will not because they actually get it. At what point in your medical training do you conclude your training is more important than the rights of your patients; do you practice ethics and empathy only when it’s serves your self interest?

      • ninguem

        I can think of two occasions in my own training, where I defied direct orders from superiors, in the interests of patients. Both cases were investigated by the department chair, two different hospitals. Both chairs had dismissed residents for such infractions. Both times I was found correct, and in fact, the patient would have suffered disastrously if I had not acted.

        Both cases revolved around “don’t do this yourself without faculty, so you don’t do your first ‘this or that’ (as you put it) unsupervised”. Thing is, beepers are not 100% reliable, in-house attending could not be found in a rapid manner.

        Actually, in one case, not a hard decision, as I had seen a senior resident follow orders directly, wait for the attending, and the patient died in the few minutes it took to find said attending and physically get on scene.

        So, on a couple of occasions, I did my first “this or that” without my faculty guidance or even permission. I doubt I’m the only physician here with stories like that.

        So, yes, I have practiced “ethics and empathy” when it has been against my own self-interest, and in fact endangered my career before it even started.

        • Ed

          Seriously, with all due respect, good for you! However, patient autonomy, informed consent, and first, do no harm are just three medical ethics your profession publicly professes. Those basic ethics don’t simply evaporate when a patient enters a teaching hospital because you believe your training takes precedence! If you can’t practice them all the time, you shouldn’t be a physician.

          • ninguem

            How’s the air up there on your high horse?

          • Ed

            Actually, it’s clear and a million; absolutely beautiful! The truth hurts doesn’t it?

          • ninguem

            must be tough being the only ethical person in the world.

  • Khaldoun

    On the other hand, many old-style doctors will tell you how much it’s now safer to practice medicine in training hospitals compared to before. We all heard from those old doctors about weekly rounds, unsupervised interns, long duty hours, and ‘learning by trying’.

    I think academic medicine has come a long way. We all should have faith in this method of practicing. It’s our responsibility as doctors who got trained in academic setting to insure that practicing this profession in academic hospitals should only increase quality of patient care while teaching a new generation how to be great doctors!

  • querywoman

    You never know when the resident, medical student, or even the janitor knows more than the senior doctor.

    • Suzi Q 38

      When my brother in law was dying of pancreatic cancer, he was still getting full on chemo and radiation.
      He was just getting worse and worse. All of it did not matter.

      The certified nurse’s aid, who was probably paid $12.00 an hour said: “Why is he still here? Just take him home. They are just going to exhaust your medical insurance and waste his precious time, what little he has left…..”

      • querywoman

        Heh! Heh! A little bit of education can be a dangerous thing! Though I see mostly specialists these days, I really like non-board certified GP’s the best.
        And this CNA was absolutely brilliant!
        It’s not all greed, though, Suzi Q. So many doctors have a salvation mentality, even though we all die.

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