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.
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
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
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.
There is a practice in medicine where new and inexperienced doctors may
learn and practice medical techniques on patients who have recently died or
are not expected to recover. A survey recently published in the New England
Journal of Medicine found that it is not at all uncommon. Should patients
be used in this way, with or without their consent?
Post your opinion here.
"Ethics Matters" Archive
where you'll find other columns from Jeffrey Kahn
on a wide range of bioethics topics.
"Ethics Matters" is a biweekly feature from the
Center for Bioethics and CNN Interactive.
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