AMA Journal of Ethics^®

Case

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.

Commentary 2

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.