TRAINEE EDUCATION IN THE ERA OF PROCEDURAL CONSENT
Abstract
In April 2024, the U.S. Department of Health and Human Services (HHS) issued new guidance regarding informed consent for procedures conducted for patients under anesthesia (asamonitor.pub/3CgmEQz). This new guidance regarding disclosure of the level of experience of all participants in medical care, and the procedures for which they will be responsible, was partially attributed to medical students who observed these types of exams being performed on patients under anesthesia without prior explicit consent. However, residents and medical students have long participated in numerous phases of medical care, and it was not uncommon for additional procedures like pelvic exams to be performed while patients were under anesthesia. Are exams performed on patients under anesthesia by learners deceptive, exploitative, or harmful?
The culture of medicine is notoriously difficult to change, and it often takes strong external forces, such as government regulation, to necessitate major modifications. Medical students and residents often feel intimidated and may not question the ethics of performing procedures on patients under anesthesia. This new guidance provided by HHS was driven in no small part by medical students who witnessed procedures on patients under anesthesia and spoke up regarding the unique position in which they were placed. Medical research and education in the United States have had numerous unethical episodes, such as an especially egregious study at Willowbrook State School in Staten Island in the 1970s in which mentally disabled patients were left in their filth and infected with hepatitis. Similarly, the Tuskegee syphilis study of the 1900s led to a loss of faith in the ethical behavior of medical professionals. New guidance provided by HHS aims to prevent lapses in ethical judgment by clinicians who seek to effectively balance patient care with the medical education of their respective learners.
Why it matters
The education of medical students and residents is critical to the future of medicine. However, it is imperative for clinicians to also protect patient autonomy and to allow them to make decisions about their own bodies. How do anesthesiologists, clinicians, and educators balance these concerns? Those who work in academic medicine commonly assume that patients understand that medical students and residents are involved in their care in a teaching institution, but this new guidance requires additional disclosure regarding the extent to which these learners will participate in medical care.
For anesthesiologists, this may include a conversation to educate a patient that, once under anesthesia, a medical student may attempt to place an intravenous line. Other examples may be that the resident will be the one performing the neuraxial procedure with instruction and guidance provided by the anesthesiologist. Issues may arise, however, with the level of detail that may be required to fully educate patients. For example, in a procedure requiring multiple lines, must the anesthesiologist discuss with the patient each individual procedure, the personnel involved with each, and their underlying education level? Does the anesthesiologist also have to discuss the level of supervision for resident learners or the composition of their anesthesia care team? The implementation of this guidance from HHS and its long-term repercussions remain to be seen.