Table 2 Ethical or Professional Issues Encountered During Clinical Training: Coded Themes/Sub-Themes and Examples of Responses from a National Survey of U.S. Fourth Year Medical Students (N = 144)
Major Coded Themes | Sub-Themes (and Examples of Students’ Responses) |
|---|---|
Professional duties | Disrespectful treatment of patient or family “A pediatrician I worked with told an obese boy that if he did not lose weight, he would go blind and they would have to amputate his limbs because of DM. This could have been explained more gently...” |
Extent or fulfillment of fiduciary responsibilities of healthcare provider “A community hospital was requiring its physicians to only refer to specialists that were within the hospital’s network of employees. Presumably, this strategy was intended to maximize profits at the potential expense of patient care…” | |
Disrespectful remarks to or about colleagues “A lot of the services at the hospitals where I’ve had rotations have acted unprofessionally with regards to “talking bad” about other services...” | |
Lack of respectful collaboration with colleagues “I feel that sometimes patient care is compromised when physicians from different specialties disagree as to patients’ treatment plans and allow the arguments to become…"turf battles.” | |
Lack of self-control “I once saw a surgeon become frustrated with a new computer system and throw a phone across the room…” | |
Deception, cheating, or misconduct in training “I have seen other medical students lie about their presence at rotation sites in order to achieve honors in that rotation…” | |
Lack of professionalism (not otherwise defined) “Multiple times, I’ve seen religion infused into a medical situation where it did not belong…” | |
Communication | Inadequate communication “Poor communication with the family of a terminal patient. The situation should have been approached with greater sensitivity, time for discussion, and more openness.” |
Deliberate lies and deception in context of medical care “OBGYN resident offered a makeshift “fertility” test to a patient just to appease the patient and her husband, despite knowing this test was not efficacious or even [done] correctly…” | |
Delivering bad news “I’ve observed a couple situations where nobody really wanted to be the one to give the bad news… I felt that the doctors should have been more straightforward with the patients and their families instead of beating around the bush...” | |
Breaking adult or adolescent patient confidentiality “Patient with CA had prognosis given to him in crowded waiting room, and doctor had to yell because the patient was hard of hearing. Ideally [the] patient should have been taken somewhere private.” | |
Disclosing medical errors “A patient was inappropriately treated by her PCP who was a provider outside our facility…I felt we should have informed the patient more explicitly that an error was made…” | |
Quality of Care | Not meeting standard of care “Resident refused to properly pad patient’s diabetic ulcers because she was going to be anesthetized for the surgical procedure. Except she was only lightly anesthetized and discomfort endangered the procedure and the patient’s safety…” |
Medical errors “Taking a patient to the OR without a CT scan - surgery aborted due to unforeseen anatomy. Better foresight needed.” | |
Treatment of pain “Giving homeless drug-seekers pain meds to get them to leave the hospital, knowing they had no care or follow-up.” | |
Student-specific issues of moral distress | Willingness to ask critical questions or speak up when concerned “Recently witnessed a neurologist spray water into a coma patient’s mouth as she said, “he was thirsty,” and then laughed. Unfortunately, [because] she’s my instructor/grader I felt helpless….” |
Uncertainties about role and scope of responsibility “Resident asked me to write notes under their computer log-in. I told her I did not feel comfortable doing so and would prefer to write notes under my own credentials.” | |
Role of religious beliefs in medicine “I worked with a pediatrician who was a strong Christian who did not support birth control or abortions. His beliefs were significantly impacting his care and recommendations to patients…” | |
Feedback on performance and etiquette “I watched an intern being put down and mistreated by an attending in front of a patient. It shouldn’t have happened or the attending should have apologized to everyone involved.” | |
Struggle over patients’ lifestyle choices “Caring for a liver failure “frequent flyer”, the team felt little compassion for the patient. The [patient] had made clearly poor life choices, however, I don’t believe this should have changed the amount/quality/completeness of his care…” | |
Learning on patients over their objections or without consent “A patient anesthetized for a surgery whom we then were asked to perform a pelvic exam to which she had not been asked or consulted to. I followed directions [because] I was unsure but wish I had not.” | |
Learning on patients without supervision or adequate skills or training “I have had a patient in the SICU [whose] prognosis is poor and the intern needed to place an arterial line. The attempts were unsuccessful and I felt there was more attempts made than should have been because she was sedated and he needed to complete the task.” | |
Decisions regarding treatment | Problems surrounding surrogate decision-making “There was a patient in my IM rotation whose POA seemed uninterested in his healthcare and never visited, was difficult during phone conversations. I felt as though we should have consulted ethics to see if we were providing the care that the patient really desired/wanted…” |
Physician disagreement with patients/surrogates over interventions “Patient with poor life expectancy…[and] wife did not want hospice or to withdraw care that likely was not helping. Palliative care consulted, but wife continued to want aggressive management…[T]eam eventually grew frustrated and antagonized [patient]‘s wife.” | |
Problems surrounding informed consent “One individual, a patient, was about to undergo a procedure. He did not speak English. When I spoke to him in his native language (in which I am fluent), it became clear that no one had properly informed him of what was going to happen or what he had consented to…” | |
Decisions related to continuing life-sustaining treatments “A patient has been on full life support for over 1 year now, because the spouse refuses to take them off…The family should be talked to again and perhaps get higher authority involved to help overrule the decision.” | |
Unclear decision-making capacity of patient “A man in the hospital was dying, and his next of kin was desperately asking the patient if it was ok for him to be comfort measures only. The patient was past the point when he could talk, but eventually weakly nodded “yes.” Ideally, this [evaluation] of life conversation would have started when the man was well…” | |
Inter-professional disagreement about patient’s best interests “Terminally ill 14 yo girl with Acute Lymphocytic Leukemia complaining of severe pain and neuropathic symptoms. Neurology consulted to evaluate and recommended an EMG…I found [the study] to be inappropriate for the situation…” | |
Justice | Discriminatory treatment “Many physicians treat patients at the county hospital differently than other populations or talk derisively of them behind their backs...” |
Inadequate level of health care “While working on the substance abuse unit a ‘no smoking’ policy was enforced. Nicotine patches were not provided for the residents and a few ended up leaving early because they could not handle the stress of the addiction and not smoking. I think that Wellbutrin, Chantrix, or nicotine patches or gum should have been provided…” | |
Wasteful or excessive level of healthcare “[E]xtra lists ordered to “rule-out” conditions for state-funded hospital stays versus more cautious ordering for private pay.” | |
Allocation of resources “…[O]n a few instances, family members have prolonged the suffering of terminally ill patients…I think more physicians should be more assertive and/or aggressive in managing these patients with their well-being in mind, as well as conservation of resources |