Insertion of femoral-vein catheters for practice by medical house officers during cardiopulmonary resuscitation

Investigation of Unethical and Unprofessional Behavior in Korean Residency Training

PHENOMENON: Medical ethics and professionalism are fundamental competencies for all physicians, and resident physicians have to develop these competencies during their training. Although Korea has a reputation for having the highest quality medical practice in East Asia, improvements in the technological aspects of care have outpaced the developments in institutional systems and education needed to fulfill social responsibility. Enhancing professionalism education during postgraduate training requires thorough exposition of this situation.

APPROACH

Twenty residents from 17 clinical departments at 1 Korean tertiary university-affiliated hospital were recruited, and in-depth interviews were conducted in person by an interviewer who was a fellow resident with participants. Interviewees recalled and described personal experiences or observations of misbehaviors that had occurred during their residency training. Researchers recorded and transcribed all interviews, and 4 researchers conducted a thematic analysis.

FINDINGS

Authors extracted 48 descriptors representing 8 categories of unethical and unprofessional behaviors from the transcripts: (a) substandard practice, (b) violation of work ethics, (c) misconduct related to conflict of interest, (d) dishonesty with patients, (e) violation of patient confidentiality, (f) lack of respect for patients, (g) lack of respect for colleagues, and (h) misconduct in research. Each of the interviewees mentioned between 3 and 18 descriptors. "Not fulfilling basic duties for patient care" was the most frequently mentioned misconduct, followed by "fabricating patient medical status or test results to meet preoperative criteria for anesthesia" and "verbal or physical abuse of junior doctors." INSIGHTS: Residents reported a diverse variety of unethical and unprofessional behaviors throughout their training and described the ethical distress they suffered in the real clinical situations. The results of this study support the notion that reinforcing ethics and professionalism education during postgraduate medical training in a practical and authentic way will help trainees manage the ethical conflicts or dilemmas they will inevitably encounter.

Simulation-based medical education: an ethical imperative

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these 2 needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Ethics seminars: the ethical debate on practicing procedures on the newly dead

Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.

Sources of ethical conflict in medical housestaff training: a qualitative study

PURPOSE

Despite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers.

METHODS

We performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues.

RESULTS

The interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients' wishes, preventing harm, managing the limits of one's competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training.

CONCLUSIONS

This study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism.

Simulation-based medical education: an ethical imperative

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Ethics of practicing medical procedures on newly dead and nearly dead patients

OBJECTIVE

To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients.

DESIGN

Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices.

RESULTS

Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement.

CONCLUSION

Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

Training bronchoscopists for the new era

Gustav Killian introduced bronchoscopy a little more than a century ago. At that time, the only way others could learn to perform bronchoscopy was by one-on-one tutoring, using a rigid bronchoscope with no side portals and no imaging devices such as a television camera and monitor. One-on-one teaching remains an integral part of learning how to perform bronchoscopy well, but many new technologies have emerged that make it far less labor intensive to train bronchoscopists. This article focuses on the training of bronchoscopists for the new era.

Perceptions of the ethical acceptability of using medical examiner autopsies for research and education: a survey of forensic pathologists

BACKGROUND

Forensic pathologists face difficult moral questions in their practices each day. Consistent ethical and legal guidelines for autopsy tissue use extending beyond usual clinical and legal imperatives have not been developed in this country.

OBJECTIVE

To obtain the perceptions of medical examiners regarding the ethical acceptability of autopsy tissue use for research and education.

METHOD

A written, self-report questionnaire was developed and piloted by a multidisciplinary team at the University of New Mexico, Albuquerque. All individuals who attended a platform presentation at the National Association of Medical Examiners Annual Meeting in September 1997 were invited to participate.

RESULTS

Ninety-one individuals completed the survey (40% of all conference registrants and approximately 75% of presentation attendees). Sixty-three percent of respondents had encountered an ethical dilemma surrounding autopsy tissue use, and one third reported some professional ethics experience. Perspectives varied greatly concerning the ethical acceptability of using autopsy tissues to demonstrate or practice techniques (eg, intubation, brachial plexus dissection) and of fulfilling requests to supply varying kinds and quantities of tissues for research and education. Most respondents indicated that consent by family members was important in tissue use decisions. Respondents agreed on the importance of basic values in education and research, such as integrity, scientific or educational merit, and formal institutional approval of a project. Characteristics of the decedent did not influence decisions to release tissues, except when the individual had died from a mysterious or very rare illness. Attributes of medical examiners, with the exception of sex, also did not consistently predict responses.

CONCLUSION

Significant diversity exists in beliefs among medical examiners regarding perceptions of the appropriate use of autopsy tissues for education and research. There is need for further inquiry and dialogue so that enduring policy solutions regarding human tissue use for education and research may be developed.