Virtual Mentor

Virtual Mentor. April 2002, Volume 4, Number 4.

Clinical Ethics in Chicago

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Patient Care and Student Education: Case for Discussion

An ethical case explores whether an attending physician should allow a medical student to place a central line on a Medicaid patient even though the student has failed the procedure two previous times.

Commentary by Caleb Alexander, MD, MS, James F. Bresnahan, SJ, JD, LLM, PhD, and Arthur R. Derse, MD, JD

Dr. Harvey was admitted yesterday to the general medical service of a teaching hospital. This is his third admission in 8 months. One prior admission was, like this one, due to exacerbation of long-standing chronic obstructive pulmonary disease (COPD). The other admission was prompted by dizziness and fainting brought on by his poorly controlled diabetes. Mr. Harvey is 57 years old and African American. Management of his health is complicated by obesity and (as he confessed to Miss Rogers, the third-year medical student who interviewed him when he arrived on the unit) his continued smoking.

A chest X-ray ordered in the emergency department before Mr. Harvey's admission shows results consistent with pneumonia. Blood culture results are not back yet. Antibiotic treatment administered intravenously is indicated, but Mr. Harvey's peripheral circulation is poor and several attempts this morning to place the IV in his arms failed. Becoming somewhat irritable with the attempts, Mr. Harvey complained that, "No one in this place can ever find my veins."

Dr. Gage, the senior resident, decides that a subclavian central line should be placed to gain intravenous access. Then antibiotics, fluids, and other medications, if needed, can be easily and effectively administered without continuing to poke at Mr. Harvey's peripheral veins.

Dr. Gage is supervising 2 third-year medical students who are in week 6 of their 8-week internal medicine rotation. The students are Mr. Crane and the previously mentioned Miss Rogers who has interviewed Mr. Harvey. Dr. Gage has established good working relationships with both students, who are highly motivated and competent. Dr. Gage takes her role as educator seriously and wants to be confident that students gain the experience and, to the extent possible, the skills they should while under her supervision.

Mr. Crane has successfully placed central lines on several occasions during his rotation. Miss Rogers has been unsuccessful on 2 attempts with different patients. Each time Dr. Gage stepped in (using her 3 sticks and you're out rule). For a couple of reasons, Mr. Harvey is a good patient for Miss Rogers next attempt. His condition is not emergent; he is accustomed to the teaching hospital routine, and has taken Miss Rogers' into his confidence. He considers her to be "on his side." On the other hand, his obesity makes the procedure more difficult than usual. Because of his multiple health problems, complications, should Miss Rogers' puncture his lung, would be life-threatening. He is already irritable about the inability of those at this hospital to "find his veins." Mr. Harvey is a Medicaid patient, and Dr. Gage is sensitive to the potential for Medicaid patients to shoulder more than their share of student and intern "practicing." Were she acting solely as clinician and not as educator, Dr. Gage would ask Mr. Crane to place the line.

Miss Rogers knows that she should succeed at placing a central line before completing her internal medicine rotation, and time is running out. She is on her way in to inform Mr. Harvey about the procedure and its risks and to obtain his consent for it. She identified herself as a student when she first introduced herself and interviewed him. They seem to communicate well. If Dr. Gage asks her to attempt to place the line, she wonders, how much will she have to tell Mr. Harvey about her past attempts. When she goes into Mr. Harvey's room, he is chatting with his grown daughter who has just arrived to see what's going on with her father.

Three commentaries on this case follow.

Commentary 1

by Caleb Alexander, MD

The Central Issue Is a Central Line.

Mr. Harvey is a patient with emphysema who has now been diagnosed with pneumonia and admitted to a teaching hospital. We are informed that the placement of a central venous catheter is clinically indicated, and at issue is the question of who is to place it and under what circumstances. This case illustrates a common dilemma for house officers and attending physicians in teaching hospitals. The primary challenge is how to best balance the potential tension that exists between the goals of providing the best standard of care to individual patients and fostering a learning environment where medical students and residents acquire the knowledge and technical skills that are critical to their developing into competent physicians. What degree of excess risk is acceptable for a patient to assume in order to offer training for novice students? Can this excess risk be quantified in particular circumstances? What are the factors that mediate this increased risk and how can they be minimized? Do the principles of informed consent require that Mr. Harvey be advised of the identity and technical competency of the person who will place the central line?

See One, Do One, Teach One.

Teaching hospitals serve an important function within our society by offering physicians-in-training the opportunity to learn the skills that they must have to become competent practitioners while attempting to provide an exceptional standard of care to individual patients. Society has an interest and investment in this process.

Naturally, achieving technical competency among physicians is a gradual process marked by several transitions. Medical students begin with lectures and anatomy lab and only after their first years in medical school do they move to the clinical setting where they participate directly in patient care. While models exist to help those in training achieve technical proficiency at different procedures (eg, practicing suturing on fruit) few would argue that these suffice at providing the exposure necessary to achieve competency.

The oft quoted expression "See one, do one, teach one" is used as a guide for many hesitant physicians-in-training as they consider their preparedness to perform bedside procedures. While the ratio of 1:1:1 is not steadfast, the transitive nature of education that it reflects is noteworthy. Those with less experience first observe a procedure, then perform one, and finally reach a stage of teaching the procedure to the next person with less experience as the cycle begins anew.

Returning to the case, there are 2 principal issues that Dr. Gage, the senior resident, must consider. First, who is to attempt the central line placement? Second, what information should the process of informed consent include? In considering these issues, Dr. Gage should consider the potentially competing goals of maximizing patient safety while fostering an educational climate for her trainees.

Who Is to Attempt Central Line Placement?

Several factors are important for the team to consider as they make this decision. What are the student's and house officer's comfort with the student performing the procedure? How acutely ill is the patient and how quickly is the procedure required? What are the patient's and family's wishes regarding who is to perform the procedure? How technically difficult is the procedure? Finally, what are the likelihood and severity of potential complications and how are these modified by the greater technical experience of more senior physicians? While perhaps the least quantifiable, the most important global measure that a senior house officer should consider in deciding who is to perform a procedure is his or her own intuition as to the appropriateness of the teaching moment. Unusual amounts of anxiety, a feeling of haste, and poor technical details (eg, lighting, height of bed, position of patient, failure to identify important physical landmarks) are the best indicators of a highly risky procedure. In this case, the combination of Mr. Harvey's comorbid conditions, the life-threatening nature of a potential complication (pneumothorax), and Miss Rogers' own perceived pressure to successfully place a central line before her rotation ends, each should give Dr. Gage pause regarding the wisdom of having her attempt the procedure at the current time.

What Should Mr. Harvey Be Told?

Let us assume that Dr. Gage and Miss Harvey carefully consider the factors discussed above and conclude that indeed this is a good opportunity for Miss Rogers to attempt the procedure. What information should Mr. Harvey be told in order to provide an informed consent? Standard components of informed consent, such as the indications, risks, benefits, and alternatives to the procedure can be discussed. The key question in this setting is how much information Mr. Harvey needs to be provided regarding the identity and technical competency of the person who is to perform the procedure. Not telling Mr. Harvey about who is to perform the procedure would deny him important information that might modify his decision. On the other hand, to tell him who is to perform the procedure while denying him knowledge of that person's technical competency seems inadequate. How then would he use the information regarding this person?

The challenge to the team is that assessing technical competency and talking about it with patients can be a difficult task. These challenges are magnified by such other common obstacles to informed consent as the acuity of illness that often characterizes the hospitalized patient. It is arguable whether a detailed a discussion of Miss Rogers' prior experience with central line placement (ie, that she has failed in 2 prior attempts) is necessary. First, such discussion risks raising disproportionate anxiety on the part of both Mr. Harvey and Miss Rogers regarding the procedure. Second, it is unclear whether Mr. Harvey (or the medical team) has the requisite knowledge to interpret the information provided—how common is it to fail an attempt at catheter placement, how does this likelihood change over someone's training and across different patients, what are the implications of a failed attempt with regard to potentially life-threatening complications such as pneumothorax?

Rather than discuss Miss Rogers' prior experience with central line placement, Mr. Harvey should be informed of the proposal that Miss Rogers, a medical student, will be the person attempting the procedure under the close supervision of Dr. Gage. Additionally, any questions that Mr. Harvey may have about Miss Rogers' experience should be addressed honestly and directly.

The Bottom Line

Virtually all senior house officers will be challenged during their training to balance the health care needs of their patients with the educational needs of their junior colleagues. Sensitivity to the mediators of procedural risk, in conjunction with an adequately thorough informed consent, should be the trainee's primary guide in achieving this balance.

Related Articles

  • Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad. Med. 1993;68:249-254.
  • Kluge EH. Informed consent in a different key: physicians' practice profiles and the patient's right to know. CMAJ. 1999;160:1321-1322.

Caleb Alexander, MD, is a post-residency fellow in the Robert Wood Johnson Clinical Scholars Program. He is working at the University of Chicago.

Commentary 2

by James F. Bresnahan, S.J., JD, LLM, PhD

Dr. Gage, the senior resident, and 2 third-year medical students are challenged in their dedication to the best interests of their patient, Mr. Harvey; it is an ethical challenge.

Although Mr. Harvey's care is reimbursed under the Medicaid program, the immediate challenge in this case does not derive from the pressure of reimbursement entities to diminish the expense of caring properly and well for their patient, though such pressure is not unknown these days. The subclavian line Mr. Harvey needs for antibiotic therapy will be provided. But the constraints on providing adequate medical education during this era when patients are moved more and more briskly out of acute care are a factor in this ethical challenge. For, though now in week 6 of her 8-week junior medicine rotation, Miss Rogers has not yet successfully placed a subclavian line. Miss Rogers, however, has been involved directly with Mr. Harvey, and has his trust—as frequently happens with a third-year student who has time to get to know a patient more thoroughly in a short time than is possible for most doctors during the rest of their professional lives.

Dr. Gage now ponders whether to assign the task of placing the line to Miss Rogers who has failed in her 2 previous attempts to do this, to turn it over to the other medical student, Mr. Crane, who has several successful attempts to his credit, or to take on the task herself.

Mr. Harvey's compromised situation gives pause to this care giver team leader's preoccupation with educational considerations. Mr. Harvey needs a steady hand and practiced eye because his fragile medical condition combined with his obesity makes a serious error in placing the subclavian line dangerous, even life-threatening.

There are reasons to believe that Dr. Gage and Miss Rogers might, by judicious restraint in their use of language, obtain Mr. Harvey's "consent" to let Miss Rogers have a go at him. On the other hand, Mr. Harvey's daughter, who is present now and concerned about him and the quality of the care he is receiving, may well foil such a ploy—and do it to the considerable embarrassment of the young physician and her students. (The possibility that the team regards Mr. Harvey, due to his non-compliance, as "deserving" to be experimented on should, of course, not even be entertained.)

This situation provides a grand opportunity for Dr. Gage to teach a very practical lesson in clinical medical ethics of the traditional kind—the kind that puts the good of the patient above all other considerations. Dr. Gage should call Mr. Harvey's attending physician and, in the presence of the 2 students, the 2 physicians should determine which of them can place the subclavian line most safely for this vulnerable patient with serious medical problems who trusts in his care givers' faithfulness to his medical best interests.

This clinical lesson—patient interests come first—may, in days and years to come, prepare us to handle appropriately the more insistent pressures we will encounter from the reimbursement bean-counters when they suggest that we compromise good clinical care of patients in the interest of dollars, not student education.

James F. Bresnahan, S.J., JD, LLM, PhD, is professor emeritus, Medical Ethics & Humanities, at Northwestern University Medical School. He can be reached at: fbresnahan@northwestern.edu

Commentary 3

by Arthur R. Derse, MD, JD

If today's medical trainees do not learn techniques such as medical interviewing, physical examination, and medical and surgical procedures through practice with real patients, not only will these trainees lack the necessary training, but tomorrow's physicians will not have the skills to care for all of us. Nonetheless, patients should not have trainees practicing these procedures without their knowledge and consent.

This case raises 3 important issues: Under what circumstances should a trainee be allowed to practice a technique? What should be disclosed in order for a patient, or patient representative, to give adequate consent? How can the burdens of medical training be distributed equitably among patients?

First, under what circumstances should a trainee practice a technique on a patient? Trainees should practice a technique in cases where the danger from their mistakes does not pose more than a minimal incremental risk over the inherent risk to the patient. Where the risk is minimal (eg, the patient is stuck with a needle for an IV without success and has additional pain from the attempt), there should be no impediment to a trainee who has been properly educated in the procedure being permitted to practice the procedure, even without supervision.

Where the inherent risk of the procedure is moderate (eg, placing a central line in someone with normal clotting abilities, with the risk of internal arterial bleeding or pneumothorax, with resolution of the complication possible by pressure or chest tube insertion) and there is minimal incremental risk in placement by an inexperienced individual, the procedure should be closely supervised. These complications can happen in the best hands, and the minimal incremental risk at the hands of a trainee should be permitted.

When the inherent risk of the procedure is severe (eg, intubation, with inherent risks of anoxia if the patient is not properly intubated), even with minimal incremental risk in attempts by inexperienced trainees, supervision should not only be close, but the trainee must have sufficient experience in other patient care knowledge and experience to warrant the intervention (eg, animal and mechanical model training or successful attempts in patients who are ideal candidates under optimal circumstances).

In the case of Mr. Harvey, the risks of placing the central line as described above are moderate, assuming that Ms. Rogers has been properly educated in the procedure, these attempts may be judged to be a minimal increment over the normal risks of the procedure, and hence permissible.

The second question is what should be disclosed to the patient? Certainly, most patients who come to teaching hospitals are aware that there are medical students, residents, and fellows in the hospital who are being trained in medicine and its subspecialties. Admission forms that patients sign explain that they may be treated by these trainees. Whether there is a legal requirement that the trainees identify themselves as trainees (and inform the patient that they are still learning the procedure) is not a settled question. Certainly the law of informed consent requires that physicians inform patients of the material risks inherent to the proposed procedure, though, in almost all jurisdictions, physicians who have been trained and are in practice are not legally required to disclose their past experience or "batting average" in order for consent to be informed.

Nonetheless, should the ethical standard be different? If the trainee is inexperienced in the procedure, this should be disclosed. Beyond the basic fact of inexperience, there should be no ethical mandate to disclose past experience with the procedure, though certainly if a patient or anyone else specifically asks the physician about his or her experience, the physician should answer truthfully. And trainees should identify themselves to patients in all circumstances. In this case, the trainee, Ms. Rogers should and did identify herself as a student.

Third, how can the burden of training be born equitably? Mr. Harvey is African American and a Medicaid patient, and care must be taken to make sure that patients in a teaching hospital are not selected inequitably for teaching practice. This is why all patients in a teaching hospital should be eligible for trainees practicing procedures.

It should be noted that studies have shown that patients do not get inferior care because they are being treated at a teaching hospital, and many state-of-the-art treatments are developed and provided at teaching hospitals. Nonetheless, patients may prefer to forgo treatment by trainees. If the patient expresses this preference, it should be dealt with honestly. Some institutions may not offer patients the choice to refuse.

In this case Dr. Gage thinks that were she acting solely as a clinician, and not as an educator, she would ask the more experienced and successful student to place the line. I would argue that if Dr. Gage were truly acting solely as a clinician who wanted the best for her patient, she would forgo both students for her own, more experienced, hand, since it is more likely that Dr. Gage with her experience, would be successful more often than Mr. Crane. Yet, just because Mr. Crane has been successful, he may not yet have learned how to avoid mistaken placement of the line. And without practice, Ms. Rogers will have no more experience and will be unable to perform the procedure when the next patient needs it, and at some point in her training, a patient will need it emergently and she will be the only one available immediately. And that patient would be better off with a well-trained physician. Finally, because Mr. Harvey has poor peripheral veins, he could well be the next patient needing a well-trained physician.

Should Ms. Rogers inform Mr. Harvey that she is inexperienced and learning the procedure? Yes. How much should Ms. Rogers tell him about her past attempts? Nothing, unless he asks, and then she should answer truthfully. Since she is a student, her past attempts are no indication of her future performance. She is learning to avoid her past mistakes.

Arthur R. Derse, MD, JD, is a senior consultant for Academic Affairs, Institute for Ethics, of the American Medical Association and associate clinical professor of Bioethics and Emergency Medicine, at the Medical College of Wisconsin in Milwaukee.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.