Every physician has stories to tell about his or her medical school
days. For example, as a third-year medical student I did my first lumbar
puncture. Then, for an agonizing hour, I thought that I would have to
find some other line of work.
The tap itself was a success, yielding clear spinal fluid (pause
for applause). However, I was slow. The tap, which should take five
minutes, took half an hour. Following protocol, as I removed my rubber
gloves I said to the patient, "Please wiggle your toes". If
you can't do a simple spinal tap without paralyzing the patient,
then you can't be a doctor.
Mrs. Smith's toes did not wiggle. Again I said, a little
louder this time and fighting panic, "Mrs. Smith, please wiggle
She said--49 years later I can still hear her--"I'm
trying, I'm trying".
Dr. Harris, the internal medicine resident supervising my learning
experience, took me into the hall. "Thompson", he whispered,
"go down to the lounge and don't talk to anybody. In an hour,
come back and re-examine her".
An hour later, Mrs. Jones could wiggle her toes! I asked Dr. Harris
what had happened. "Thompson", he said, "sometime when
you have thirty free minutes, lie down on your side with your knees
pulled up to your chin and see if your feet don't go to
I was an unlicensed, unqualified, recent college graduate. Why was
I performing a risky invasive clinical procedure? Because I was watching
sausage being made. This is how doctors get to be doctors.
Whether the procedure is lumbar puncture, joint replacement or open
heart surgery, true learning only begins when one approaches a patient
with needle, knife or laser in hand. As Mark Twain said, "A man
that has swung a cat by the tail has learned sixty or seventy times as
much as a man who has only talked about swinging a cat by the
Conventional wisdom is that clinical skills can only be taught by
those who are clinically skillful. Therefore, for 2,400 years the
medical profession has been kept alive by physician teachers. The
Hippocratic Oath includes: "1 pledge ... to give a share of
precepts and oral instruction and all the other learning to my sons and
to the sons of him who has instructed me and to pupils who have signed
the covenant and have taken an oath according to the medical law, but no
However, in recent years parts of the Hippocratic Oath have become
obsolete. (1) For example, the original oath also requires physicians to
give money to sons of colleagues who are strapped for cash. Modern
revisions of the oath wisely omit this expectation.
Regarding physicians as teachers, the admonition to teach "no
one else" has been removed. Today's doctors teach nurses, a
variety of allied health professionals, and patients. How far does the
obligation to teach extend?
For example, what if a non-physician wants to learn and practice
surgical skills? Specifically, Packer and others (2) ask, "What if
a university department of ophthalmology offers a hands-on course on
surgical management of eyelid lesions and markets the course to
ophthalmologists and optometrists? And, "What if a politically
active optometrist asks an ophthalmologist to whom he refers patients to
show him how to perform minor eyelid surgery?"
Relevant ethical (moral intelligence) issues include preservation
of the professional ethic by protecting patients from potential harm,
fairness to those wishing to learn new clinical skills, and truth
Should a physician teacher be concerned with the safety of a
student's patients? Packer et al, state, "When an
ophthalmologist undertakes to treat a patient, he or she implicitly
invites trust and promises competence and avoidance of harm. That same
responsibility should guide the ophthalmologist teacher who is extending
his or her patient care impact by empowering others to deliver care.
In a teaching hospital, the physician teacher may have no choice.
Dr, Harris, the internal medicine resident supervising my first lumbar
puncture, was expected to teach the medical students assigned to him.
On the other hand, a practicing physician has a choice. A properly
motivated refusal to share clinical expertise could be heeding the
cardinal principle of the professional ethic, primum non nocere, first
do no harm.
Isn't there a simple and obvious solution to this dilemma? Why
not rely upon state professional licensing laws? An optometrist is a
limited license practitioner, and limited licenses do not ordinarily
include the right to prescribe drugs and do surgery Case closed, right?
The role of physician extenders is extending further than some
might have originally envisioned. Almost every specialty now has its
version of the debate in obstetrics about the role of midwives vs. MD
obstetricians. Anesthesiologists have long taught and employed
GRNA's (certified registered nurse anesthetists).
I was a pioneer in teaching new-born intensive care unit nurses to
take on new clinical responsibilities. And, relevant to the eye, in
Michigan an optometrist can obtain a TPA (therapeutic pharmaceutical
agent) certificate that includes the right to secure a license to
prescribe controlled substances. (3)
We couldn't settle for a legalistic answer as an ethical
endpoint, anyway. When ethical issues are punted to the law, the result
may or may not be morally intelligent.
We can, however, ask ourselves, what is the rationale for
distinguishing between fully licensed and limited license practitioners?
Sometimes there is none. Sometimes licensing laws are influenced by
effective political activists from one professional association or
The rationale should be presumed differences m clinical training
Technical competence is not all there is to being a responsible
surgeon. Is development of surgical judgment a goal of optometry
training programs? What operation should be done in what instance, and
when should no operation be done at all: furthermore, what happens if an
optometrist encounters an unexpected surgery-related complication? Would
he or she be able to handle it?
This line of reasoning should not lead us to conclude that
optometrists will never ever be qualified to remove a basal cell
carcinoma from someone's eyelid. Indeed, if efforts to reform
health care are serious, perhaps patient-centered professionals will
happily teach limited license practitioners to perform a limited list of
procedures. Patient safety and accessibility to care must both be
The flip side of the patient protection issue is this: What if an
ophthalmologist actually recruits optometrists to learn surgical skills,
then establishes a chain of inconsistently supervised branch offices? In
other words, what if the professional ethic is trumped by
That kind of exploitative profiteering can lead a country to the
brink of bankruptcy, which definitely suggests need to be morally
Fairness to learners
Surely fairness always demands that a physician share his knowledge
and skills with an eager learner. That" might be true if all
requests to be taught were fair. We cannot assume that they a re.
In fact, there b another legal aspect to this issue that sometimes
rears its ugly head. Believe it or not, some seeking instruction might
issue a threat, veiled or direct, of the following nature: "This is
my attorney and she says that if you do not teach me to do this surgical
procedure then that is restraint of trade and we will sue."
That should not work. The law has an interest in patient protection
that should trump an activist's desire to create a test case,
barring a confirmed attempt to unfairly limit competition.
I didn't say the threat absolutely won't work. Again I
say, the law sometimes does strange things. If you are ever confronted
with such a threat, on this or any other matter, do not make the mistake
that a good professional often makes. That is, don't think: "I
should be able to work this out."
Rather, tell people making the threat that their threat seals the
deal--mere win be no immediate instruction--and tell them that your
attorney is now handling the matter for you.
By the way, old time theoretical ethicists would consider that last
point "legalistic contamination of what should be a pure ethical
Modern day practical ethics applied theorists might say:
"Poppycock. Without honest acknowledgement of this practical side
of the issue, ethical reasoning is but an irrelevant game played by
ivory tower academics."
To tell the truth
Truth telling may be the premier ethical principle because without
truth telling there can be no trust and without trust there can be
neither meaningful individual relationships nor sustainability in
As an eye patient myself, my perspective on this issue involves
truth telling. Bruce (my excellent ophthalmologist), if you ever send an
optometrist to do an ophthalmologist's job on my eyelid, then at
the very least you must tell me and give me the opportunity to refuse
(1.) Thompson RE. I swear by Apollo, the Hippocratic Oath is
Obsolete. The Physician Executive, 300(2):60-3, March-April 2004.
(2.) Packer S, Parke DW, Pellegrino ED. Should ophthalmologists
teach surgery to optometrists? Archives of Ophthalmology 126:1458-9, Oct
Richard E.Thompson, MD
Former vice president of the Illinois Hospital Association, author
of Think Before You Believe, Xlibris, 2005.