Video: Commitment to Honesty with Patients | Commentaries

A Faculty Perspective

Medical trainees need to learn to do clinical procedures to become competent physicians, and the learning process will expose some patients to additional harm and discomfort because of the trainees' inexperience. Rebecca's situation raises questions related to trainee qualifications and the appropriate disclosure to patients. In the pediatric setting, these issues are complicated because of the unique characteristics of procedures in children and the reliance on parents to protect the child's interests.

first question for Rebecca is whether she is at the point in her own professional development that she is technically prepared to do the procedure. Has she mastered requisite procedures, such as drawing blood and the use of sterile techniques? Does she understand the cognitive aspects of the procedure, i.e. the anatomy, the risks, etc? Some trainees may have excessive exuberance for procedures while others demonstrate persistent avoidance. Supervisors of trainees must play a role in determining if a student is prepared, rather than just relying on the trainee's personal assessment. Rebecca may be ready, but the supervisor would have to ask about her experience to make this assessment.

A second question for Rebecca is whether this procedure is necessary for her specific professional development. The impact of a failed or bloody LP on an infant with a fever includes prolonged antibiotic treatment or selecting the wrong antibiotic. Given these serious consequences, compensating benefits are necessary. LPs should only be performed by those trainees who are likely to be doing LPs on infants as part of their career. As a third year medical student, Rebecca does not need to do this LP. However, if she were planning on a career in pediatrics, the risk can be justified.

So when Rebecca becomes a pediatric intern, should she inform the mother that this is her first LP and should she ask for permission? More central to pediatric training than learning to do an LP is learning to respect families, to communicate effectively, and to build trust with parents. Such disclosure and permission can help Rebecca achieve those goals, regardless of whether the mom agrees to allow Rebecca to do the LP.

Some trainees may worry whether a patient would ever agree to be the intern's first spinal tap. But disclosure is particularly important for those parents of patients who would not agree, so they can have their wishes respected. The challenge for Rebecca and her resident is for them to communicate confidence, care, and respect, so that the parent might agree. It will be important to explain not only the risks of the procedure itself, but also the nature and likelihood of those risks for a first time procedure (in this case, an inconclusive diagnosis), that Rebecca will be supervised, and replaced, if she is having difficulty. Parents must also be given the alternative of having the supervisor do the LP. This discussion can increase the therapeutic alliance between the medical team and the mother and will permit Rebecca to ask questions while she is performing the procedure without having to pretend she knows what she is doing. Learning how to communicate with parents about uncertainty, inexperience, and the need for consultation and advice, is much more challenging and more important to learn that doing a spinal tap on an infant.

References:

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Christakis, D. A. and C. Feudtner (1993). "Ethics in a short white coat: the ethical dilemmas that medical students confront." Acad Med 68(4): 249-54.

Feudtner, C. and D. A. Christakis (1994). "Making the rounds. The ethical development of medical students in the context of clinical rotations." Hastings Cent Rep 24(1): 6-12.

Feudtner, C., D. A. Christakis, et al. (1994). "Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development." Acad Med 69(8): 670-9.

Gamulka, B. D. (1998). "The need for true informed consent in pediatric teaching hospitals." Acad Med 73(6): 628-9.

Gordon, H. H. (1979). "Advice to medical students preparing for clinical clerkships." Pharos Alpha Omega Alpha Honor Med Soc 42(2): 9-16.

Wendler, D. S. and S. Shah (2006). "How can medical training and informed consent be reconciled with volume-outcome data?" J Clin Ethics 17(2): 149-57.

Williams, C. T. and N. Fost (1992). "Ethical considerations surrounding first time procedures: a study and analysis of patient attitudes toward spinal taps by students." Kennedy Inst Ethics J 2(3): 217-31.

Benjamin S. Wilfond MD
Department of Pediatrics, University of Washington School of Medicine
Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital