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See one, do one, teach one: where do we draw the line?
Subject:
Medical students (Education)
Medical ethics (Evaluation)
Interns (Medicine) (Social aspects)
Interns (Medicine) (Practice)
Medical teaching personnel (Management)
Medical colleges (Faculty)
Medical colleges (Management)
Author:
Thompson, Richard E.
Pub Date:
01/01/2009
Publication:
Name: Physician Executive Publisher: American College of Physician Executives Audience: Professional Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2009 American College of Physician Executives ISSN: 0898-2759
Issue:
Date: Jan-Feb, 2009 Source Volume: 35 Source Issue: 1
Topic:
Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management
Geographic:
Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:
192693970
Full Text:
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 your toes".

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 sleep".

Making sausage

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 tail."

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 one else".

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 telling.

Protecting patients

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.

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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? Wrong.

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 another.

The rationale should be presumed differences m clinical training and experience.

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 served.

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 entrepreneurial opportunism?

That kind of exploitative profiteering can lead a country to the brink of bankruptcy, which definitely suggests need to be morally intelligent.

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 argument."

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 business.

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 care.

References

(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 2008.

(3.) http://www.michigan.gov/documents/cis_fhS_DhSer_OpU2_O3memO_589O7_7.pdf

Richard E.Thompson, MD

Former vice president of the Illinois Hospital Association, author of Think Before You Believe, Xlibris, 2005.

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