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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