Table 4.
Clinical vignettes: students’ statements
| Clinical vignette 1 | |
|---|---|
| Themes | Verbatim |
| Unconditional care | “Our job, as health-care professionals, is to help persons in pain and to relieve their discomfort. I treat this patient without hesitation, gladly even.” (3) |
| “First, we must take care of his pain. We practice a humanist and altruistic profession, it is our duty to treat him.” (2) | |
| “I take him, I treat him free of charge, and no differently from how I would treat somebody who would pay” (6) | |
| “After an interview to understand and diagnose why the patient is suffering, I treat him and prescribe the appropriate medications. The consultation is free in consideration to the distress and pain of the patient.” (2) | |
| Care on condition | “He either gives me a guarantee that he can pay me later, or he goes and sees another dentist.” (6) “I treat him, and ask for a guarantee for a later payment (he gives me his ID card for guarantee during the time he goes to get some money.)” (2) “It depends on whether I know him. If I don’t know him, then he’ll have to find the money somehow, or otherwise produce exceptional empathy.” (6) “I try to take into account his needs, but I will not take as much time to take care of him as I would with another patient.” (2) |
| Focus on social aspect | “I first take the time to look at the clinical situation and then suggest a solution so that the pain stops. Then, if he cannot pay for the next consultation, I help him obtain social benefits.” (2) |
| “Emergency care to calm the pain, then referral to social assistance structures that can take care of dental care.” (6) | |
| Directs patient toward other public health structures | “I ask him what health insurance cover he has. Or I refer him to a hospital emergency service. I explain that treatment doesn’t come free, just as he can’t just go into a shop and come out with something without paying for it.” (6) |
| Clinical vignette 2 | |
| Themes | Verbatim |
| Beneficence | “I explain that I can not carry out a dental care that I know not to be the best for him.” (6) |
| “I try to convince him. I explain that as a health-care professional, I can tell what needs to be done, and I’m bound by medical duty to do what’s best for him, and if he insists he wants the tooth out, and if that’s really the wrong solution, then I tell him to go and see another dentist.” (2) | |
| Patient autonomy, decision-making, and practitioner status | “I must explain to him the best course of action and try to convince him without any obligation. If the patient maintains his opinion, I am obliged to respect him and to do what he wants.” (2) |
| “I describe his dental condition, that his tooth can be kept, that the conservative treatment is less damaging than an extraction, and I assure him that I’ll do all I can to make sure he won’t feel anything (topical anesthetic, etc.). If he insists, we talk about it and I tell him about the different options. In the end, it’s up to him to choose, even if I don’t approve his choice.” (3) | |
| “I try to convince him, if I really can not, I do what the patient asks, after all it’s his mouth.” (3) | |
| Care consumer patient | “The patient comes to appeal to our skills, he is a ‘consumer’ so we must bring him what he wants, even if it’s not our way of thinking (except if life and death situations). I will therefore bend to the choice of the patient.” (3) |
| Superiority of dentist over patient or paternalism | “We again explain that this tooth can be kept, that it is not necessary to carry out an extraction. We are a doctor, we judge what to do and the patient accepts or will go elsewhere. The patient does not govern our opinion.” (6) |
| “I explain again that the tooth can be conserved, and that there’s no need to have it out. I’m a dentist and I decide what should be done, and the patient just must accept that or go and see someone else. It’s not for the patient to decide for us.” (6) “We explain why extracting the tooth would be a big mistake. In any case, the patient can not force us to perform this act. So if he persists, it must be reoriented to another practitioner who, perhaps, will agree to extract this tooth. The practitioner, in this sector, has a certain “superiority” toward the patient; we must not grant a request if it seems unreasonable.” (3) | |
| Postpone the decision | “We precisely explain to him that there are other alternatives and he is given a period of reflection to change his mind.” (2) |
| “I calmly explain the situation with the risks and benefits of proposed treatment. I try to answer his questions and try to level the information according to the patient. If we do not agree, I explain that I can not perform an inappropriate medical procedure and I propose another appointment to give us time to think.” (3) | |
| “I think we need to take time to explain the different solutions available. The advantages and disadvantages of each solution must be explained. It must also be made clear that extraction has aesthetic and functional consequences. It may also be wise to give the patient time to reflect and make a decision. We can offer another appointment and we can suggest that someone, whom he trusts, come with him.” (3) | |
(2) = second-year student, (3) = third-year student, (6) = sixth-year student
In this document table, all references to “him” meant the patient