Follow Informed Patient Consent in Clinical Teaching in Order to Achieve a Truly Patient-Centered Approach

Abstract

Patient- and disease-focused clinical teaching is considered the cornerstone of medical education. Current clinical teaching is increasingly taking place in outpatient settings, but this can cause discomfort to patients. Although many professional organizations have developed a set of ethical considerations in response to this issue to use these considerations to guide clinics in their outpatient procedures, these guidelines are not well adhered to in outpatient practice. My experience as an eczema patient in a dermatology outpatient is good evidence of this. In my opinion, there is nothing inherently wrong with the pedagogy of medical students observing clinical interactions in outpatient settings; the real problem lies in not informing the patient of the medical student's presence or allowing the patient to exercise his or her right of refusal. Therefore, the following recommendations are made: First, academic medical centers should provide regular training to doctors and medical students to ensure that they are fully aware of what is contained in the ethical guidelines established by the professional organizations and that they recognize the importance of adhering to these guidelines in clinical practice. Second, each clinical teaching activity should have the informed consent of the patient and be based on the patient's wishes. Finally, it is recommended that hospitals establish appropriate evaluation mechanisms to assess doctors’ compliance with the ethical guidelines and provide continuing education and training for doctors and medical students who fail to comply.

Introduction to the Issue

About a year ago, I suffered from severe eczema. My hands and feet were covered with red, scaly patches, and I spent many nights tossing and turning due to an indescribable itch, often scratching the affected areas to relieve the itch, which resulted in numerous breakouts and bleeding on my hands and feet. Despite visits to primary care dermatologists and the use of a variety of topical medications, the results were not significant. To get rid of my eczema, I decided to go to one of the best general hospitals in China, whose dermatology department is ranked among the top three in China. To ensure the effectiveness of the treatment, I made an appointment with one of the most famous dermatologists. When I arrived at the door of the dermatologist's outpatient room on the appointed day, I found the doorway crowded with patients, which is very common in China and a common sight for everyone. When my name was called by the outpatient appointment system, I pushed my way into the room. The moment I pushed my way in, I realized that in addition to this highly respected dermatologist, the room was filled with almost a dozen junior doctors and medical students who had been taught by him. Being one of them (I am an MSc graduate who also studied with senior doctors in the outpatient setting during my medical school years), I was not visibly uncomfortable with this. The dermatologist was also used to teaching medical students in the outpatient setting and had no intention of asking me if I wanted a medical student to observe the entire procedure. The dermatologist gently asked me about my medical history and kept tapping on the keyboard to record what he thought was important information. The consultation took about a minute and everything seemed very natural. Then this dermatologist said take off your shoes and socks and show me the patches on your feet. I quickly took off my shoes and socks as he asked and found what I thought was the best angle to show him the eczema lesions that were giving me a very hard time. At that moment, he suddenly said to the dozen or so students in the back, “Come see, all of you, this is a very typical manifestation of eczema.” In an instant, a dozen people rushed forward to examine my feet, and I could hear others whispering and commenting. Because it happened so suddenly, I didn't even have time to react to whether or not I agreed with them looking at my feet. As a result, an extremely complex emotion flooded through me that could have included fear, anxiety, discomfort, shame, and anger. Although the whole process took no more than 30 s, it felt extremely long, and I felt like an animal in a circus or zoo, to be viewed at will by tourists. Afterward, to get out of the uncomfortable situation quickly, I hastily answered a few more questions from the dermatologist before quickly fleeing the outpatient room. Suffice it to say, that this dermatology visit left a serious shadow on my heart.

Key Factors for Consideration

When I got home and calmed down, it dawned on me that if someone like me, who was once a medical student, felt uncomfortable and helpless about what I was experiencing in the consulting room when I switched to the role of the patient, what would it mean to the patients who never knew this would happen when it happened to them? Will there be expressions of protest and dissatisfaction? At least in my time as a medical student and intern, this never happened, and every patient expressed acquiescence and cooperation with all of this, because in the outpatient room, the doctor is the strong party, the patient needs the doctor's help, and no patient dares to challenge the doctor's authority at that time. As doctors and medical students, it is important to realize that it is the willingness of patients to cooperate that provides medical students with better learning opportunities, and that patients make a significant contribution to the education and training of medical students. However, this is not a given for patients. In addition, doctors should offer patients the right to refuse, even if this creates a conflict between the educational needs of medical students and the needs of patients. ¹ I note that the American Medical Association and others have developed a set of ethical considerations to guide clinics in their outpatient procedures (eg, informing patients of the presence of a medical student or allowing patients to exercise their right to refuse).^2,3 However, as a patient, it puzzles me why these considerations are not strictly enforced in outpatient practice. People don't care enough about the patient to pay attention to how this makes them feel. It should be clarified that, as a patient, I see nothing inherently wrong with the teaching method of medical students observing clinical interactions in the outpatient setting. I am also willing to help improve the professional competence of medical students whenever possible. After all, producing more doctors with greater professional competence is beneficial to patient care. However, I want this to be done with my informed consent. Thus, the real problem is not informing patients that a medical student is present or allowing them to exercise their right to refuse.

Perhaps the root cause of this problem is that there is still an overemphasis on technology in hospitals and medical schools, where almost every doctor and medical student wants to improve his or her clinical skills to cure patients quickly. ⁴ In such cases, perhaps patients are often seen as malfunctioning machines rather than as living, breathing, emotional human beings. Thus, a patient-centered culture has been promoted throughout the healthcare system in recent years, ⁵ and much research has been done to show doctors how to treat patients more empathetically. However, from the patient's point of view, I would argue that little has been accomplished.

Recommendations

In my opinion, from the patient's perspective, at least for the ambulatory teaching scenario, improvements need to be made in the following three areas.

1. Emphasize the importance of adherence to ethical guidelines in clinical practice. Academic medical centers should provide regular training to doctors and medical students to ensure that they are fully aware of the ethical guidelines established by relevant professional bodies and the importance of adhering to these guidelines in clinical practice. At the same time, it is necessary to train doctors and medical students in humanism so that they learn to think differently, ie, to imagine themselves as patients and to think about whether their actions will be accepted by patients or not. ⁶

2. Doing informed consent. When a senior doctor wants a junior doctor/medical student to observe in the consulting room, it is important, on the one hand, to inform the patient of the presence of the medical students (particularly when there is a large number of medical students, the patient's discomfort may be more severe) and, on the other hand, to obtain the patient's consent by the ethical guidelines. And make it clear to the patient that whatever he chooses, it will not affect the doctor's behavior in treating him. At the same time, the academic medical center is obligated to inform the patient of his/her right to know and to refuse the presence of a medical student in the outpatient setting.

3. Establish an evaluation mechanism in hospitals to regularly assess, through patient surveys, whether doctors are strictly applying the above principles of informed consent, and, based on the results of these surveys, provide continuing education and training to doctors and medical students who have violated the principles of informed consent.

Conclusion

As a former member of the cohort of medical students, I am aware of the considerable effort invested by each individual in attaining the status of a fully fledged doctor. Furthermore, I am cognizant of the intense aspiration among these students to enhance their professional capabilities. Despite the discomfort this experience caused me, I was still willing and able to adopt the perspective of these interns and accept the situation. Because it is necessary to promote the development of the professional skills of junior doctors/medical students in all appropriate ways. But when it comes to patients, doctors must put themselves in the position of their patients, who have emotions. Therefore, it is important to follow ethical guidance and confirm the patient's consent to have medical students observe the medical examination.

Author Biography

Hongnan Ye holds a master’s degree in medicine. His research interests include medical ethics, medical education and patient experience.