Patients for Practice?
January 25, 2000
Web posted at: 3:52 p.m. EST
(2052 GMT)
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for
Bioethics
University of Minnesota
Physicians can only learn so much from books, journals,
classrooms and computers. Someone has to be their first patient for
every procedure. This includes everything from taking a medical
history, to drawing blood, to performing more complex and invasive
procedures. But
there is a practice in medicine where new and inexperienced doctors
may learn by working with patients who have recently died or are not
expected to recover. A survey examining this little-known aspect of
medical training was recently published in the New England Journal
of Medicine, and it found that it is not at all uncommon. How should
we balance the need to train doctors against the rights of patients
not to be misused?
More practice means
better doctors
I don't want to be the first patient for any doctor -- his first
case of a particular disease, her first surgery of a particular
type, or the first time he takes a particular sample. I'd just as
soon my doctor practiced on someone else first. While that view is
universal, how and when are doctors supposed to get the practice we
patients want? Medical students practice looking in each other's
ears or listening to their classmates' hearts, and there are
actually professional "model patients" who allow doctors-in-training
to use them to practice examination techniques. And when it comes to
more invasive procedures, there are even special mannequins for
practicing drawing blood or inserting tubes. But these are merely
second best, and there always has to be a first live patient.
Getting more than you
expect
We can be somewhat comforted by the fact that first-timers will
be at least trying to help their patients. Also, students and
trainees are taught to inform patients that this is the first time
they've drawn blood or sewn up a cut. Patients mostly accept this
because they are informed on admission that medical training is part
of what goes on in teaching hospitals or clinics, and that trainees
may be present and even participate with supervision in patient
care. All this is well and good. It is acceptable because it serves
both the interests of training future health care workers and the
medical care of patients.
But practice on patients who are dying or have recently died
doesn't meet this standard, since such training has nothing to do
with what patients need and for which consent is not obtained. And
it is difficult to imagine that anyone would or could give consent
through a blanket statement saying that care in a teaching hospital
includes trainees practicing techniques that won't help you once it
has been determined that you are likely to die. Whose interests come first?
Trust between doctors and patients is already under assault --
managed care organizations seem to be intruding in medical
decisions, and prestigious medical research is being halted for
taking advantage of research subjects. Like in the argument made
against physician-assisted suicide, will patients trust their
physicians to do the most they can for them if they know that
physicians also help kill people, or practice medical procedures on
patients who don't need the procedures? It cannot help to have one
more reason to wonder whether physicians will do only what is in
patients' best interests. Patient welfare must be re-established as
the touchstone and guiding principle in medical care to restore that
trust. The practice of medicine must include practice, but not at
the expense of patients treated like training dummies without their
knowledge or consent.
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