The Tavistock Principles

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Rights: People have a right to health and health care.

Balance: Care of individual patients is central, but the health of populations is also our concern.

Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health.

Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.

Improvement: Improving health care is a serious and continuing responsibility.

Safety: Do no harm.

Openness: Being open, honest, and trustworthy is vital in health care.

As students you will learn about some of the ethical challenges that will con-nt you later as a practicing clinician. However, there are dilemmas unique the role of student that you will face from the time that you begin taking care of patients. The following vignettes capture some of the most common experiences. They raise a variety of ethical and practical issues that are overlapping.

Scenario #1

You are a 3rd-year medical student on your first clinical rotation in the hospital. ^ It is late in the evening when you are finally assigned to the patient that you are responsible for "working up" and presenting the next day at preceptor rounds. ^^ You go to the patient's room and find the patient exhausted from the day's events and clearly ready to settle down for the night. You know that your intern and attending have already done their evaluations. Do you proceed with a his tory and physical examination that is likely to take 1 to 2 hours? Is this process only for your education? Do you ask permission before you start? What do you include?

Here you are confronted with the tension between the need to learn by doing and doing no harm to patients. There is a utilitarian ethical principle that reminds us that if clinicians-in-training do not learn, then there will be no future caregivers. Yet the dictums to do no harm and prioritize what is in the patient's best interests are clearly in conflict with that future need. As a student this dilemma will arise often.

Obtaining informed consent is the process for addressing this ethical dilemma. Making sure the patient realizes that you are in training and new at patient evaluation is always important. It is impressive how often patients willingly let students be involved in their care. It is an opportunity for patients to give back to their caregivers. Even when clinical activities appear to be purely for educational purposes, there may be a benefit to the patient. Multiple caregivers provide multiple perspectives. This scenario invokes the Tavistock Principles of openness, balance, and safety.

Scenario #2

You and your supervisor are on your way to draw an urgent blood sample from a patient. The patient was admitted with hypernatremia (a high sodium level) and needs to have his electrolytes monitored closely. It is already past the time for a repeat blood draw. Just then your supervisor is paged to an emergency and asks you to draw the sample on your own. You have seen several done but have only done one yourself and that was a few weeks ago.

In this situation you are being asked to be responsible for clinical care that exceeds your capability. This can happen in a number of situations, such as being asked to evaluate a clinical situation without proper backup or to complete DNR forms with a patient before you have been taught how. In the setting above, you may have the following thoughts: the patient will benefit by having a test that needs to be obtained; or, the risk to the patient from a venipunc-ture is more one of discomfort or pain rather than one that threatens his or her life, and you have already drawn blood once before. There is educational value to the learner in being pushed to the limits of his or her knowledge to \ve problems and to gain confidence in functioning independently. But what ie right thing to do in this situation? In this scenario, think about the Tavi-stock Principles of openness, cooperation, and safety. You may need to find another person who is more qualified to do the procedure; or you may choose to attempt the venipuncture after alerting the patient to your inexperience and obtaining the patient's consent.

Scenario #3

You are assigned to a clinical team taking care of 25 patients who must be seen and have notes written on them before other commitments start at 7 a.m. There ^^ are four of you: the resident, an intern, a 4th-year medical student, and you, a ^^ mid-year clinical clerk. It is now 5:30 a.m. After the patients are divided among ^^ the three more senior members of the team, with time allowed for writing orders and notes, there are barely 5 minutes to assess each patient at the bedside. After seeing nine patients with the resident, you are asked to write three of the notes. You have questions about the care of several of the patients but realize that there is no time to ask. Feeling uncomfortable, you write the notes to the best of your ability.

This situation relates to the Tavistock Principles of comprehensiveness, cooperation, openness, and improvement. As these scenarios illustrate, clinical students are under pressure to go along with practices already in place. The context may be the way a team works on an in-patient service or the standard approach to patients in an emergency room or an outpatient clinic. You may find yourself choosing between cooperating as a member of a team and delivering care that is not consistent with your individual sense of quality. In addition, often you are working with clinicians who are evaluating your performance as a student. You may find yourself doing tasks that make you uncomfortable because of pressures to be a "team player."

As you can see, ethical dilemmas frequently occur in the life of clinical students. Because, as a student, you are often in a hierarchical situation where you have relatively less power, ethical conflicts that you have no control over may arise more often than when you are a practicing clinician. You can also see that often there are no clear or easy answers in such situations. What responses are available to you to address these and other quandaries?

You need to reflect on your beliefs and assess your level of comfort with a given situation. In some situations there may be alternative solutions. For example, in Scenario #1, the patient may really be willing to have the history and physical examination done at that hour, or perhaps you can renegotiate the time for the next morning. In Scenario #2, you might look for an alternative supervisor for the venipuncture. You will need to choose which situations warrant voicing your concerns, even at the risk of a bad evaluation. Seek out coaching on how to express your reservations in a way that maximizes that they will be heard. As a clinical student, you will need settings for discussing these immediately relevant ethical issues with other students and with more senior trainees and faculty. Small groups that are structured to address these kinds of issues are particularly useful in providing validation and support. Avail yourself of these opportunities whenever possible.

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