AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2005, Volume 7, Number 1.

Module 4

  • e-mail |

Case 4.1: Balancing Patient Care and Student Education—Mr. Harvey's Central Line

Related topic: Medical students as "patients"

Just as it is important to get permission for students to perform procedures on patients, trainees should also be aware of the ethical concerns surrounding the use of their peers as "patients" for training purposes.

Opinion 3.09, "Medical Students Performing Procedures on Fellow Students"

(1) In the context of learning basic clinical skills, medical students must be asked specifically to consent to procedures being performed by fellow students. The stringency of standards for ensuring the explicit and non-coerced informed consent increases as the invasiveness and intimacy of the procedure increase.

(2) Instructors should explain to students how the procedures will be performed, making certain that students are not placed in situations that violate their privacy or sense of propriety. The confidentiality, consequences, and appropriate management of a diagnostic finding should also be discussed.

(3) Students should be given the choice of whether to participate prior to entering the classroom and there should be no requirement that the students provide a reason for their unwillingness to participate.

(4) Student should not be penalized for refusal to participate. Thus instructors must refrain from evaluating students' overall performance in terms of their willingness to volunteer as "patients."

Medical students pretending to be patients are not in a patient-physician relationship with each other. Consequently, the information disclosed to students should differ from that disclosed in a clinical context. Students should also consider the potential effect of the exam and the possible (unexpected) findings on their relationships with fellow students. As the invasiveness or intimacy of the procedure increases, greater care must be taken to ensure that students' informed consent is explicit and uncoerced.

Voluntariness and the forces that may undermine it deserve special scrutiny in this context. It should be recognized that coercive influences may stem from individuals or from situational factors, eg, the mere fact that students are in an educational setting and are being evaluated. Some students may have conditions that they do not wish to reveal but that might be detected upon physical examination. Unless they are presented with an explicit choice to volunteer, students may feel compelled to submit to the procedures, especially if they believe that their participation impacts the evaluation they receive from instructors. Instructors should refrain from including students' willingness or unwillingness to participate as a contributing factor in their evaluations. Some students may give reasons for not participating as "patients," but reasons should not be required, and the decision not to offer reasons must be respected.

In short, students should be given the choice to volunteer in a non-coercive setting prior to entering the classroom and there should be no requirement that the students provide a reason for their refusal to participate.

Next Case

Module 4 Table of Contents

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.