1. A Teaching Hospital Challenge: Balancing Patient Care and Medical Student Education [Insert Name of Presenter] Ethics Resource Center American Medical Association

2. A Challenge Under what conditions should medical students be allowed to perform procedures on patients? Ethics Resource Center American Medical Association

3. The Patient Mr. Harvey is a 57-year-old patient with a history of COPD and insulin- dependent diabetes mellitus. He is admitted with a 3-day history of fever, productive cough, and shortness of breath. Ethics Resource Center American Medical Association

4. Diagnosis and Treatment Chest X-ray reveals a right lower lobe pneumonia. IV antibiotic treatment is indicated. Ethics Resource Center American Medical Association

5. Gaining IV Access Mr. Harvey’s peripheral circulation is poor and several attempts to place a peripheral IV were unsuccessful. Dr. Gage, the senior resident, decides to insert a subclavian line to administer the IV antibiotics. Ethics Resource Center American Medical Association

6. The Medical Students Dr. Gage is supervising 2 third-year medical students who are in week 6 of their 8-week internal medicine rotation. Ethics Resource Center American Medical Association

7. Medical Students’ Experience One of the 2 medical students, Mr. Smith, has successfully placed central lines on several occasions. Miss Rogers has been unsuccessful on 3 previous attempts with different patients. On Miss Rogers’ last attempt, Dr. Gage had to step in to place the line herself, following her “3 sticks and you’re out” rule. Ethics Resource Center American Medical Association

8. Ethical Dilemma Should Dr. Gage permit Miss Rogers to attempt a central line placement in Mr. Harvey? Ethics Resource Center American Medical Association

9. Finding a Balance The primary challenge for Dr. Gage is finding the appropriate balance between providing quality patient care and fostering a learning environment for medical students. Ethics Resource Center American Medical Association

10. Relevant Considerations Assessing risk to patients of having a medical student perform the procedure. Informing the patient of the student’s participation and ensuring the patient’s willingness. Equitable distribution of the burden of medical education among patients. Ethics Resource Center American Medical Association

11. 1. Assessing Risk Dr. Gage should consider: Inherent risk of the procedure for a specific patient. Incremental risk of allowing a student to perform the procedure. Ethics Resource Center American Medical Association

12. Key Determinants of Inherent Risk Patient-Related –Clinical status- eg, stable, emergent –Co-morbidities- eg, obesity, diabetes Procedure-Related –Invasiveness of procedure –Technical complexity of procedure –Potential harm from failed attempt Ethics Resource Center American Medical Association

13. Examples of Inherent Risk Categories Minimal Risk –Intramuscular injection; non-emergency clinical setting. Moderate Risk –Placing a central line; patient with COPD. High Risk –Intubation; emergency clinical setting. Ethics Resource Center American Medical Association

14. Key Determinants of Incremental Risk Incremental risk is the added risk of a student’s performing the procedure. Key determinants are the students’: –Knowledge base –Experience with patients –Performance of similar procedures Ethics Resource Center American Medical Association

15. Assessing Risk Categorizing inherent and incremental risk can help one reach a decision concerning student participation. Ethics Resource Center American Medical Association

16. Ethics Resource Center American Medical Association

17. Risk Category Implications Category 0 –Student should be allowed to perform the procedure without supervision. Category 1 –Student should be allowed to perform the procedure with a supervisor nearby. Category 2 –Student should be allowed to perform the procedure under close supervision. Ethics Resource Center American Medical Association

18. Risk Category Implications Category 3 –Student should be allowed to perform the procedure under close supervision after the patient has given explicit informed consent. Category 4 –Student should not be allowed to perform the procedure on this specific patient. Ethics Resource Center American Medical Association

19. Inherent and Incremental Risk to Mr. Harvey In Mr. Harvey’s case the inherent risk in placing a central line is moderate. The incremental risk is moderate because of Miss Rogers’ level of experience and previously unsuccessful attempts. Ethics Resource Center American Medical Association

20. Risk Assessment Implications In a case with moderate inherent risk and moderate incremental risk (Risk Category 2), It is permissible for a medical student, like Miss Rogers, to perform the procedure under close supervision with the patient’s knowledge. Ethics Resource Center American Medical Association

21. 2. Informing the Patient Dr. Gage should: 1. Inform Mr. Harvey of the inherent risks of the proposed procedure. 2. Inform him that Miss Rogers, a medical student, is learning the procedure under her (Dr. Gage’s) supervision. Ethics Resource Center American Medical Association

22. Information Disclosed Miss Rogers does not have to disclose information about her past attempts. If Mr. Harvey asks about past attempts, his questions should be answered honestly. Ethics Resource Center American Medical Association

23. 2. Ensuring Willingness The AMA Code of Medical Ethics requires that the resident or attending physician ensure that the patient is “willing to permit [student] participation.” Ethics Resource Center American Medical Association

24. Informed Consent If the clinical circumstances is determined to be Risk Category 3: –explicit informed consent must be obtained from the patient before the medical student performs the procedure. Ethics Resource Center American Medical Association

25. 3. Distribute the Burden of Medical Education Equitably Dr. Gage is sensitive to the potential for Medicaid patients and members of minority groups, like Mr. Harvey, to shoulder more of the burden of medical students’ learning. Ethics Resource Center American Medical Association

26. Participation in Medical Student Education The burden of medical education is not shared equally among patients. VIP -- and many other-- groups of patients are less likely to participate in medical student education. Ethics Resource Center American Medical Association

27. Participation in Medical Student Education All patients whose treatment calls for given procedures and, Whose condition qualifies them, Should be viewed as candidates for participating in the training of medical students. Ethics Resource Center American Medical Association

28. Encouraging Patient Participation in Medical Student Education Patients in teaching hospitals receive the benefits of team care including the time and attention of medical students. Without patient participation, the education and training of the next generation of physicians is undermined. Ethics Resource Center American Medical Association

29. Take Home Lessons Physicians can balance patient care and medical student education by: –Assessing risk of student participation. –Supervising students accordingly based on risk assessment. –Educating patients about the benefits of student participation in medical care, and the their role in training the next generation of physicians. Ethics Resource Center American Medical Association

30. References 1. The Council on Ethical and Judicial Affairs. Medical students’ involvement in patient care. The Journal of Clinical Ethics. 12;2001:111-115. 2. Joint Commission on Accreditation of Hospitals, Accreditation Manual for Hospitals, 1985 Edition (Chicago: Joint Commission on Accreditation of Hospital, 1984). Cited by: The Council on Ethical and Judicial Affairs. Medical students’ involvement in patient care. The Journal of Clinical Ethics. 12;2001:111-115. 3. Cohen DL et al. Informed consent policies governing medical students’ interactions with patients. Journal of Medical Education. 62;1987:789-798. Cited by: The Council on Ethical and Judicial Affairs. Medical students’ involvement in patient care. The Journal of Clinical Ethics. 12;2001:111-115. 4. Beatty ME, Lewis J. When students introduce themselves as doctors to patients. Academic Medicine. 72;1995:175-176. Cited by: The Council on Ethical and Judicial Affairs. Medical students’ involvement in patient care. The Journal of Clinical Ethics. 12;2001:111-115.

31. This ethics educational presentation was created by the: Ethics Resource Center American Medical Association 515 North State Street Chicago, IL 60610 Phone: (312) 464-5257 Fax: (312) 464-4799 Email: erc@ama-assn.org Web: www.ama-assn.org/go/erc