Ethics of Medical Instruction

Susannah Emerson

It so happens that a good number of my friends are currently in medical school. This means that I see them rarely and that when I do see them, I flood them with my many questions. The things I've learned through them inspired this piece, for which I surveyed a number of med students about the sticky ethical dilemmas that they face on the regular. This is not an exposé on the inner workings of elite American Medical Institutions, nor is it a critique of common practices, rather, it's a contemplation on the challenges of training humans to perform miracles. For the moment, I won't be focusing on medical miracles themselves, though there are surely trillions to point to. Here, I list the anecdotes I heard that gave me pause, made me squirm, made me ask "Is that even okay?" 

I heard about a resident who accidentally cut through a patient's liver during an operation while the doctor had left the room after asking the student to finish the job. The patient was never informed of the mistake during an otherwise routine procedure. (Though apparently this isn't quite as big of a deal as it sounds as the liver is pretty great at healing itself.) 

I learned that it's common practice for med students to perform their first pelvic exam on a woman while she is under general anesthesia prior to another procedure. A number of students will put their hands inside the patient, one after the other. Most female patients will probably not have read the fine print that alerted them to the possibility. 

I learned that students doing rounds go to work sick all the time as it's almost impossible to make up the work and learn what you need to otherwise. 

I learned that doctors take credit for the work of others. On the whole, the examples were minor such as a student taking intake and progress notes, or cauterizing or stitching a wound next to a doctor while the doctor says, "I'm stitching you up right now" or the likes.  

I learned that each of the students I surveyed had a list of surgeons who they would never let operate on them, doctors who they wouldn't trust with their lives. In some cases, it was a matter of skill, and in some, it was a matter of ego:  "They are not open to suggestions from others, and that’s where medical errors come in."

I learned that people who present differently receive different care. The example that one student used was, "A 20-something woman with tattoos who had unprotected sex, whose diabetes is poorly controlled, who comes in for a skin infection and is in pain, is identified as drug seeking. And when I asked to make sure that we are not undertreating her pain because of our preconceived ideas of her social history and life decisions, I am made to feel like a silly naïve person, because clearly tattoos and unprotected sex equals a person faking pain for opiates. Side eye."

I learned that hospitals are extremely hierarchical, meaning that the highest ups often dominate. Of course they determine the culture of the hospital, but sometimes individual doctors overrule or sway patients, their families, and inferior, but perhaps more involved, professionals within the medical field. One student said, "We had a patient who was only 50-something years old, who had a cancer diagnosis that had a 6-month prognosis. [He] was quickly declining. I saw him in his 4th month after diagnosis, and he had blood in his lungs. The palliative chemotherapy wasn’t working to make him comfortable. And oncologists, I learned, lose a lot of patients and therefore become quite aggressive in wanting to treat treat treat, which I understand ... But after having a family meeting with the patient ... the whole rest of the family over the phone, the patient decided to stop with treatment. But the oncologist wasn’t in that meeting and wanted to proceed with a risky procedure, which another team had refused to do because the risks outweighed the benefits. The residents, palliative care team and I didn’t know how to navigate these conversations, again because [of the] hierarchy played into these discussions. So the conversations, uncomfortably for everyone, continued to dance around the ideas of death versus the rhetoric of fighting, giving in, and other phrases that make it so that somehow in cancer people have to be heroes and fighters and that otherwise it is giving up, instead of making the decision to have a good death. The end is that he did end up getting the procedure. And thankfully he did well through it. But what if the outcome was different?"

I learned that many medical professionals become desensitized, not to the value of life, but to the patient experience. It's common that their focus shifts to their own lives: their fatigue, their pain, their psychological well being. "A lot of time we are just too tired to change anything and just try to get through the day." If this is a bad thing, it's also fundamentally human. That said, the best course of action is, obviously, for students to take care of themselves. Get a therapist. Get enough sleep. Get enough to eat. Get together with loved ones. Get outside. Get some exercise. It's logical enough, but none of the above is made particularly easy by the pace and rigor of med school, and all of the above gets in the way of being in the hospital, saving lives. 

Above all, I've learned that in medicine, "watch one, do one, teach one" is a popular phrase. That's how the learning happens, and it's as good a system as I could come up with. So for example, a student will watch a pap smear in clinic, and then later that day perform one themselves. One day, a student goes from never having delivered a baby to being the first person to hold a newborn. They go from practicing sewing up pig skin to sewing up a person's back. It also turns out that talking a concerned family member or patient through what has just or what will soon happen goes differently in real life than it does in the textbook scenarios that med students practice.

As one student I spoke to said, "the very basis of medical training is that you are learning to perform tasks that you have never done before." That is, students are performing tasks that they are underqualified for all the time, and they must continue to do so if we want them to be able to save lives and teach others to do the same in 20 years' time. We need our med students to learn, but the realities of the learning experience are often jarring.

Some medical students are raising children; some are caring for dying parents; some are breaking up with girlfriends; some are managing bipolar disorder; some grew up surrounded by bigotry; some were traumatized by bigots. Environmental factors and individual circumstance cannot be eliminated. (Nor would I want them to be. I value humanity and compassion in a doctors a lot.) But that also means that medicine is not and cannot always be a student's highest priority. 

In school, I always wanted to do my best, the best even, but there was always something else to care about and be consumed by. They are students, in the same way that I was a student in seventh grade memorizing all of the countries in South America, but they've memorized body parts, and their tests are ultimately not on paper, but on people. These are high stakes, and then we add in human variation.

Only 50% of us have a psoas minor muscle in our abdomen, so though a student might know where the psoas minor should be, they can't know if the patient they're about to see has one. I grew up with a friend whose heart was on the right side of his body (that's the side that it's not on for the rest of us). All of his organs are reversed which means that every single well informed medical student in the country would be absolutely wrong if they were asked to point to his spleen. 

The human body is impossible to know entirely, and impossible to "get right." Still we task a highly motivated, very able subsect of people with learning the body, and getting it right or getting sued if they don't. Doctors go through so much school to gain enough experience to operate based on more than just theory because no body works as it should or would in theory. This much is obvious, but still we hold doctors up to the highest ethical and legal standards, which sometimes includes faulting them for failing to execute the perfect practice. That too makes sense. We want the doctors who hold lives in their hands to do so responsibly. 

These overlapping priorities don't point (or don't point me) to a clear code when practicing, studying or teaching medicine. All they do is leave me with increased awe, admiration, worry, envy, and gratitude towards these people who fix bodies but are also in and limited by their own bodies.

So, thanks! And study hard! And take care of yourselves!