Assessment of doctors in training: should patients give consent?BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7538.431 (Published 16 February 2006) Cite this as: BMJ 2006;332:431
All rapid responses
All of us are acutely aware of the very low level of training
opportunity that is available to junior doctors.
The big mistake is accepting that all that the trainees do is "work"
and hence European Working Time Directive (EWTD) applies to it all.
But junior doctor training is an apprenticeship which is a
combination of service (work) and training/learning. Hence this should be
formally distinguished, and EWTD should apply only to the Work part.
For example, an SpR should have the stipulated 48 (or 30!) hours per
week of WORK and another 30 of 40 (or as many as we+they decide are
required) hours per week of LEARNING which is formally timetabled and NOT
counted as work.
Or better- we formally stipulate that 40% of the time a Junior Doctor is
in the hospital he/she is purely learning and 60% is purely working. This
may sound artificial, but is necessary for protecting the very existence
of surgical and medical training.
If that is accepted- then they can be around to learn for 66% longer.
So out of the 80 hours a trainee is in the hospital, 48 hours is work and
hours is learning. OR, of the 90 hours a trainee is in the hospital,
54 hours is work and 36 hours is learning or postgraduate studentship. Of
course, no salary need be paid for these learning/postgraduate studentship
hours, and they are not included in the EWTD hours count.
Such Work + Postgraduate Studentship will then match the training
most of us have undergone; and if implemented the eager trainees will be
"allowed" to be in their alma mater- the place of learning -- the hospital
- long enough for adequate training/education.
It is too simple a concept, but if this model works, it could be
applied to the rest of the World.
Competing interests: No competing interests
Editor - Lawler stipulates that it is indicated to obtain written
informed consent from patients taking part in assessments of clinical
skills as part of postgraduate training programmes (1).
The ultimate goal of optimising competency based training and
assessment in medical education is the delivery of the best possible
doctors and specialists in the best interest of current and future
patients. The question arises whether explicitly asking informed consent
from patients participating in clinical education really serves this goal.
The willingness of the majority of patients to take part in numerous
authentic learning situations at all levels of competence is both highly
appreciated and essentially inevitable. Their co-operation is the backbone
of medical training.
When performing a complex task for the first time - be it
communicating bad news or doing a laparoscopy - performance below
professional standards seems more likely than by the time a trainee has to
take a summative assessment. Finally obtaining consent only when a patient
is asked to participate in a formal assessment does not seem rational. To
be honest, the greatest risks are probably involved afterwards, when
someone starts practising independently without supervision, as is the
case with newly licensed drivers.
Requesting patients to agree explicitly whenever a trainee is
involved in their care would eventually ruin learning, teaching and
assessment in clinical practice. Overzealous requesting of consent is
impractical, may cause avoidable anxiety and may even seriously harm
individual patients since it interferes with trustworthy patient-doctor
relationships between trainees and their patients.
Thus, seemingly paradoxical, asking informed consent with respect to
clinical training may not always be in the best interest of current and
future patients. This should be reserved for selected procedures such as
video recordings. Instead, we have to guarantee supervision of trainees at
all times and teach trainees to develop adequate professional attitudes to
seek supervision and assistance whenever they feel the need. Disseminating
ample information among the public about the importance of the role of
patients in clinical education and their rights seems to merit more
attention than it generally gets.
1. Lawler P G. Assessment of doctors in training: should patients
give consent? BMJ 2006; 332: 431 (18 February)
Competing interests: No competing interests