The use of patients for learning and maintaining practical skills

Abstract

Throughout their careers, doctors have an ethical obligation to consider the benefits and harms of treatment, and choose the most appropriate for each patient, resources allowing. There is also a legal requirement to practise to acceptable standards together with a professional requirement to participate in continuous medical education/professional development. The General Medical Council (GMC) states 'Doctors are responsible for maintaining their professional competence and standard of performance...'1 and 'You must keep your knowledge and skills up to date... '2. There is a corresponding duty to educate others: 'You should be willing to contribute to the education of students or colleagues.'2 A doctor's prime duty, however, is to 'Make the care of your patient your first concern'2—a duty that sits awkwardly with the other duty to learn and maintain less familiar skills that might be required for other patients. This conflict has implications for respecting patients' autonomy, gaining consent for treatments and upholding standards of practice. For example, fear of complaint or legal action motivates many anaesthetists specifically interested in airway management to stop teaching others on procedures or maintaining their own skills (debate and discussion, Difficult Airway Society Annual Meetings, Edinburgh 1999 and London 2002), despite recognized deficiencies in these skills.3 Most of their concerns relate to informed consent for specific procedures or parts thereof—even though many consider them 'routine'. Such concerns may not be unwarranted: there are discrepancies between what patients would wish to be informed about and what anaesthetists feel they should be informed about.4 The published work tends to neglect this dilemma, instead focusing on junior trainees, medical students, or practice on the recently dead,5-7 but it merits wide debate especially at a time when specialist training is being curtailed and new consultants will be short of practical experience.8,9 Here I discuss the following questions. What is a 'procedure' and how can one decide whether its components can or should be considered separately—for example, regarding consent and choice? How can doctors balance their obligations to the present patient with those to future patients and society? Do patients themselves have obligations to other patients such that they ought to participate in doctors' learning or maintenance of skills? And how can the practitioner reconcile these conflicts while respecting patients' autonomy? Finally, I offer a stepwise, practical approach based on consideration of these questions.