Should I do what they say to secure that grade A?
It was four weeks before my finals and I,
like all my colleagues, was feverishly
trying to grab what clinical experience I
could get. I was on a busy geriatric firm, and I
had plenty of opportunity to practise the
invasive procedures that a house officer needs
to survive on the wards. The elderly patients
were mostly willing to "let the student have a
go" and I made the most of the sessions to
advance my skills. It was only when I was
asked to perform a femoral arterial stab (a
painful procedure) on
patients who could not give
consent that I began to wonder if what I was being asked
to do was ethical.
One patient was comatose and the other had
advanced dementia, but the
doctor encouraged me to "have a go." My
mind raced at this point, torn between the
conflict I felt: my natural desire to acquire
clinical skills was balanced by an uncomfortable feeling that neither the patients nor
their relatives had consented to the procedure. In the end I refused. I felt considerable
unease at being put in this position. Did I act
correctly? Should I have just taken the
opportunity being offered? Even more worrying at the time, could I have harmed my
assessment on the firm by refusing?
In an editorial this month Len Doyal
discusses the ethics of provision of clinical
education and suggests a framework to
guide both teachers and students when
interacting with patients (p 130). The guidance is comprehensive, but I doubt whether
much of it is achievable in
practice when initiated by
students. I have been placed
in uncomfortable positions
where I have felt conflict
between my ethics and
desire to learn. But learning
is not the whole matter. Students are now in an examination setting
every day with the present educational fashion of continual clinical assessments. Rub.
bing the consultant up the wrong way
because you disagree with an unethical
request could lead to problems when the
assessment sheet is marked. It is hardly a
recipe for success. Few students could be
blamed for turning a blind eye and
conforming to the order of the consultant.
Clinical students walk this ethical tightrope every day - to refuse or object when
placed in an unethical situation you have to
be brave and tread carefully. It is often the
arrogant clinician, with little interest in
ethics, who puts the student in this difficult
position, and too often it is the same
arrogant clinician who grades the student.
The move towards continuous assessment
rather than a final clinical examination,
while offering some advantages, has meant
that students are under even greater
pressure to conform and not rock the boat
during clinical attachments.
I returned to medical school after
postdoctoral research and teaching students, and I have been amazed by the clear
deference expected of medical students with
regard to the absolute authority of clinicians.
The stark reality is that we are often
expected to assume a serf-like acceptance that "the clinician is always right" even
when clear ethical boundaries are breached. I have
tried, not always with success and not without risk of
incurring the wrath of an
irritated teacher, to maintain my ethical
beliefs. But the sad fact is that the
application of ethical principles by students
is difficult in practice. Partly this is because as
students we often experience little respect
from a profession steeped in the expectation
that students conform to the hierarchical
structure and the belief that "teacher knows
best." To do otherwise can invite failure in
the short term.
To stand up for what you know is
ethically right, even when it risks inviting
ridicule or prejudice from a superior, takes
courage as a medical student. We are not in
a profession that encourages dissent from
the lower ranks. It may mean that your
grades suffer, and that is antithetical to some
students who are force fed the idea that high
grades equate with being a
good clinician. But do good
grades, achieved via indifference or apathy towards
ethical practice, translate
into becoming a good doc.
tor if your only excuse is "I
was just following orders"?
Too many unethical and immoral acts in
history were supported by such a statement.
The root of the problem lies in respect.
Until the culture in medicine changes
towards a mutual learning contract between
teacher and student, with respect flowing in
both directions, students will continue to be
forced to turn a blind eye to unethical practice. Some educators might still prefer the
Lancelot Spratt school of medical education, with absolute obedience from students,
but does it make for a profession where we
practise best care for our patients? I think
not, and I hope that you agree with my decision to "just say no."
Alan Woodall, final year student doctor, Leeds School of Medicine
Email: Alan.Woodall@themutual.net
studentBMJ 2001;09:129-170 May ISSN 0966-6494
