AMA Journal of Ethics^®

Case

Jon was a second-year internal medicine resident at a large, academic medical center. Through a series of coincidences, he encountered two patients in clinic whom he believed would benefit from enrollment in a clinical trial getting underway at the center. The trial, about which Jon was particularly knowledgeable, was being conducted by the chairperson of the Department of Medicine, Dr. Anderson. Jon contacted the study coordinator about the patients, and then explained the risks and benefits of participating in the trial to patients.

The following week, at the conclusion of grand rounds, many faculty members, residents, and students were mingling outside the auditorium and grabbing a last cup of coffee before heading back to work. Jon was catching up with a few of his fellow residents when Dr. Anderson stopped to thank him for enrolling the patients in the trial.

“We’ve had a heck of a time getting patients recruited for this study, so I appreciate all the time you spent getting them enrolled,” Dr. Anderson said.

After asking how Jon’s current rotation was going, Dr. Anderson said, “By the way, I have tickets to the game Saturday, and I’ll be out of town, so you’re welcome to them if you can use them. Just let me know.”

Commentary

Placing patients in a clinical trial is one of the cornerstones of academic medicine and I believe these participants are real heroes—especially those who consent to a prospective randomized trial prior to knowing which arm of the study they will be assigned to. It is customary for the investigators running the trials to have funding, primarily so that the clinical trial’s nurse can be paid for following the patients and filling out the requisite case-report forms. Often research is funded on a per-subject basis, so it is important to recruit as many patients as possible who qualify. In the past, our institution has given tokens of appreciation to faculty or residents (as in this case) who helped enroll subjects. Past rewards have included books, certificates to book stores, travel to the clinical trial meeting, and even a percentage of the payment per case. These tokens, however, were described in writing prior to the trial and available to everyone.

Many new regulations aim to manage potential conflicts of interest between industry and physicians. It would make sense to practice these common-sense principles with those who work with us.

In this scenario, thanking Jon for placing the patient in the clinical trial is appropriate—and can be done in front of others. What is not acceptable is offering the gift of the tickets in the same conversation. Quite possibly the conversation took place by accident, and Dr. Anderson did not intend to offer the tickets to Jon before he ran into him. The offer, nonetheless, shows favoritism and should not have been made. Even presenting the tickets to one resident in front of others without any mention of the patients’ being placed in the trial is not appropriate when the person offering the gift is the chairperson or someone who is of superior status to the resident. Jon should make an appointment with Dr. Anderson, turn down the tickets, and tell him how uncomfortable he felt when the offer was made. Doing so would help Dr. Anderson understand how his gesture could have been perceived as a reward.

As a department chair, I invite our chief residents to dinners for visiting professors, but I invite them all. I give them each a holiday gift, and, when they are on my service, I encourage them to attend events with or without me—again due to their present role—not because of who they are personally or as a payback for something they did for me.

The field of surgery has become a club or family or, as Jerry Shuck, a former chair of surgery at Case Western Reserve called us, a clan [1]. We may sometimes step over the line of appropriate behavior because we spend long periods of time with our residents in the operating room, often during life-and-death struggles. True, we probably should adopt a more business-like relationship with them that still enables us to know and mentor them, and give every resident the same chance for a close but appropriate relationship with those who represent departmental leadership.

Since our current residents are from many different backgrounds, it is most important to keep our interactions fair and above board. As leaders, we also need to learn that a “thank you” is more than enough. Most employees, students, residents, and faculty feel that thanking them for a job well done is plenty. It means their efforts were noticed and attention was paid to the small contributions we are all making. Instead of tickets, take good care our patients—and take good care of our residents, staff, and colleagues.