On a Mission: Know Your Limits

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By Alison Hayward

A medical student volunteering at a surgical treatment camp in Africa is offered the opportunity to assist on a surgical procedure, and enthusiastically accepts. As the surgery progresses, the physician overseeing the case offers the visiting student increasingly greater responsibility. The medical student, thrilled to be given the opportunity to participate so directly in patient care, finds himself performing the surgery, with instruction from his mentor. His hands, unused to the surgical tools, slip, and perforate the patient’s bowel. As the surgeon steps in to repair the damage, the student nervously contemplates his own actions, questioning whether he should have refused his mentor’s offers before things went too far…*

A short time ago, I posted messages to the Student Doctor Network Forums, asking whether any of the physicians, pre-medical students, or other pre-health professionals had ever taken a clinical action outside of their ability in medicine while working internationally – either due to being put into a situation where their care was the only care available, creating pressure to perform beyond their means, or they found themselves in a situation where a colleague or supervisor had willingly offered them a chance to do something that they were not qualified to do. I received only a single response – from a practitioner who had not witnessed any such behavior from medical professionals while abroad, but reported that the “see one, do one, teach one” philosophy seemed highly prevalent.

Although I was unable to interview any Student Doctor Network members about their experiences with this issue, upon review of available literature, numerous examples of practice outside the scope of a trainee have been presented in the literature.

A poignant 2009 article by Amy Levi on the topic of international nursing student electives presents the story of a medical student on an international elective who refers to himself as “Dr. Jones” and is summoned to the bedside of an ill child in the village. In the story, which “combines elements of actual situations with fictional details”, Dr. Jones attempts to offer treatment recommendations to the dehydrated and febrile child’s family. The child subsequently dies, provoking widespread distrust of visiting medical professionals amongst the villagers.

In another case presented in an issue of Virtual Mentor, a third year student named “Phil” staffs a rural clinic in El Salvador while on an elective. The surgeons overseeing him instruct him to put on a long white coat and call himself “doctor”. They put him in charge of prepping patients for surgery and closing the surgical incisions, tasks he would be unlikely to be assigned in the United States. When a patient he cared for returns with a wound infection, Phil questions his mentors and is told “Relax, the rules here are different than at home… Is it better for the patient to get less expert care or no care at all?”

Let’s ask the patient suffering the surgical wound infection.

Several articles on this subject have made a trenchant analogy to a healthcare practitioner from a country in the developing world traveling to the United States on vacation and offering free medical care to our citizens without appropriate training or a license. Most would see this situation as clearly inappropriate and frankly, illegal. There are many Americans who lack access to medical care under our current healthcare system, and yet somehow the argument that unskilled medical care might be better than no care at all rings hollow when put into this context.

To further answer whether medical trainees might ever be ethically justified in providing such care while on elective, we can also turn to the literature to review the debate. The consensus of medical ethicists on this question seems clear cut. The British Medical Journal has stated that students should not take on the role of a qualified doctor, “irrespective of any encouragement which students may receive from members of the host organisations to which they are attached. This includes not diagnosing, prescribing, or treating any patient without strict clinical supervision.” An article on this issue in the Journal of Medical Ethics described the BMJ’s view thus: “They feel that students fail to appreciate the dangers of treatment, particularly where familiar medical problems are complicated by unfamiliar poverty… It is unethical to ‘practise’ on the local population because it has the misfortune to be poor.”

Similarly, in his analysis of the case of “Phil” the medical student, Naheed Rehman Abbasi says that the argument “the rules here are different than at home… cannot be justified on ethical grounds,” citing the AMA’s Code of Medical Ethics, which opines: “training must be structured to provide [trainees] with appropriate faculty supervision….with graduated responsibility relative to level of training and expertise.”

The commentary concludes that medical students being misrepresented as doctors is a violation of the AMA’s Code of Ethics, and also that it is the responsibility of the trainee to refuse to perform procedures that they do not think they are trained or competent to perform. I believe that this conclusion misplaces the preponderance of the blame. Phil does question his supervisors as to whether it is appropriate for him to care clinically for the patients in ways that would not be allowed in the United States, and the supervisor argues that his actions are appropriate.

Ideally, trainees should feel that they can freely express their discomfort with performing patient care tasks to which they are not accustomed – but it is unlikely that a trainee would feel empowered to question the ethics of his or her mentor, whom that trainee is likely counting on as a reference for a future letter of recommendation. The onus should be on the mentors supervising trainees to be fully familiarized with physician standard codes of ethics in regards to global health, and to teach students to behave in a way consistent with those ethical standards. The power balance in the relationship is skewed towards the supervising clinician, and as such, that supervisor must be aware that students can be vulnerable to being put under pressure to bring potential harm to patients by undertaking procedures and delivering care which he or she is not capable of safely providing.

One particularly intriguing example of the type of ethical quandary into which students can be placed is presented by Dr. Ross Donaldson, a fellow emergency medicine physician, in his book The Lassa Ward. This memoir provides a fascinating glimpse into a place where few foreigners venture – a remote part of Sierra Leone in west Africa where viral hemorrhagic fever is endemic. Donaldson completed his third year of medical school, then did a year of public health training, and decided to write a thesis on Lassa fever, for which he arranged to gain direct experience by traveling to the specialized treatment ward for Lassa fever run by an experienced local physician. Donaldson’s mix of idealism, enthusiasm, bravery, and frankly, foolhardiness makes for an interesting read.

Soon after Donaldson arrives, he volunteers to work with a colleague to process samples of blood taken from patients exposed to Lassa fever. Such a process, if undertaken in the United States, requires a biosafety level 4 laboratory, which would entail a positive pressure protective suit with a segregated air supply, entry and exit with airlocks, vacuum, showers, and other protections designed to decontaminate the lab workers. Donaldson and his colleague have few such protections in place in their mobile lab. In contrast, the medical school with which my hospital is affiliated does not allow any medical student to perform invasive procedures on a patient known to be infected with HIV or hepatitis, as a health safeguard. In the book, Donaldson describes volunteering for this task because he wants to help his colleague expedite the sample processing, which he successfully does. It could be argued that Donaldson has the right to risk his life in this way if he has weighed the risks and benefits of doing so. However, if Donaldson had made an error in the lab that had caused himself or his colleague to get infected with Lassa fever, they would likely have become patients in the Lassa ward, capable of infecting others in turn. This perspective makes the risks taken seem less reasonable.

Donaldson then begins work at the Lassa ward, where he rounds with his supervising physician, Dr. Conteh. Abruptly, Donaldson is put on the spot by Dr. Conteh when the physician states that he is departing on a field visit and that he is leaving Donaldson in charge of the ward. Donaldson is panicked at the idea and tries to protest, but Dr. Conteh presses him to take on the challenge, and soon Conteh has departed and left Donaldson to care for the critically ill patients on the service. All are suffering from deadly Lassa fever, and some of the patients have complicating factors such as pregnancy, and there is a pediatric patient on the ward as well as a number of adults. Donaldson manages by consulting reference books and papers he has brought with him to the hospital, asking questions of the nursing staff on their usual protocols.

This tale truly puts to the test the standard dogma about trainees on international medical electives. Despite Donaldson’s protestations, Dr. Conteh is unmoved and does not agree to stay in the ward. If Donaldson refuses to care for the patients on the ward, the nursing staff are the only medical professionals remaining who can perform these tasks, and Donaldson quickly finds that their foundation of knowledge, despite having a great deal of practical experience, is lacking. Ethical analyses of such situations often make exceptions if the patients are in life-threatening danger or if a truly emergent situation arises and the medical student is, in fact, the most qualified person available to treat them. Lassa fever is certainly a deadly disease, and the patients are indeed at high risk. By this yardstick, it would seem that Donaldson acting as a physician, despite his lack of qualifications and knowledge, might be justified by the extenuating circumstances.

Dr. Conteh’s decision to leave the ward in Donaldon’s hands, despite his assertions that he is unable to properly care for the patients, is harder to justify. Donaldson points out that Dr. Conteh is the only local physician willing to care for patients suffering from Lassa fever, and that he has worked tirelessly serving these patients for many years, although he had the opportunity to leave the country and work in a far more comfortable and less dangerous setting. Dr. Conteh tragically died of Lassa fever himself not long after Donaldson’s visit. It is difficult to accuse Dr. Conteh of being any less than an extremely hardworking and dedicated physician, however, his exemplary conduct evidenced by the rest of his professional career does not forgive the lapse in ethical judgment he demonstrates in this scenario.

These thorny ethical issues will continue to become more commonplace as international electives continue to rise in popularity, and students travel to more remote destinations for exotic experiences. Patients should always be informed of a student’s training level and asked for consent to be seen by a student. Additional protections should be put in place for trainees to protect them against the potential for unscrupulous mentors pressuring them to push beyond their limits in the provision of care to patients, and also to remind overzealous trainees of the boundaries they must be aware of with respect to their actions while they are traveling. Some medical schools have adopted codes of conduct for their students while rotating abroad, which lay out a variety of ways in which the student should strive to model ethical conduct. These include not undertaking clinical care for which they have not been trained or certified to provide. All medical schools which allow for international electives should require students and site supervisors to review and sign off on such codes of conduct prior to departure on their elective. Discussions of ethical issues should be included as part of an orientation for the elective, and reflections on the experience should be encouraged upon return, and shared with others at the home institution to promote an environment where ethical considerations and concerns can be freely discussed and addressed when they arise.

* The opening vignette is based on a story reported by a colleague, although details of the case have been changed to assure anonymity.

Alison Schroth Hayward, MD, MPH is a board certified emergency medicine physician at Yale New Haven Hospital. In 2003, she co-founded a nonprofit called Uganda Village Project, and currently serves as the chair of the board. Any expertise she has in global health ethics has mainly resulted from making the mistakes already herself, and trying to learn from them.

References
Aabasi, N and Godkin, M, Limits on Student Participation in Patient Care in Foreign Medical Brigades, Virtual Mentor. December 2006, Volume 8, Number 12: 808-813.

Banatvala, N and Doyal, L. Knowing when to say “no” on the student elective BMJ 1998;316:1404

Bradke, A. The ethics of medical brigades in Honduras: who are we helping? (2009) Found at: http://d-scholarship.pitt.edu/8620/1/Bradke.pdf

Donaldson, R. The Lassa Ward: One Man’s Fight Against One of the World’s Deadliest Diseases.

Pinto, A and Upshur, R. Global health ethics for students. Developing World Bioethics. Volume 9, Number 1:1-10.

Radstone, S J. Practising on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. J Med Ethics 2005;31:109-110.

Roberts, M. Duffle bag medicine. JAMA. 2006;295(13):1491-1492.

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