National Ethics Teleconference

***Should Patients Be Able to Refuse Care by House Officers or
Trainees?***

## March 24, 2004

# INTRODUCTION

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health
Care and a physician at the VA NY Harbor Healthcare System. I am very
pleased to welcome you all to today\'s National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of important VHA ethics
issues. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# ANNOUNCEMENTS

Remember, CME credits are available for listeners of this call. To get
yours go to <http://vaww.ees.aac.va.gov/ethics>

Ground Rules: Before we discuss whether today's topic, whether patients
should be able to refuse care by house officers or trainees, I need to
briefly review the overall ground rules for the National Ethics
Teleconferences:

-   We ask that when you talk, you please begin by telling us your name,
    location and title so that we continue to get to know each other
    better. During the call, please minimize background noise and PLEASE
    do not put the call on hold.

-   Due to the interactive nature of these calls, and the fact that at
    times we deal with sensitive issues, we think it is important to
    make two final points:

    -   First, it is not the specific role of the National Center for
        Ethics in Health Care to report policy violations. However,
        please remember that there are many participants on the line.
        You are speaking in an open forum and ultimately you are
        responsible for your own words, and

    -   Lastly, please remember that these Ethics Teleconference calls
        are not an appropriate place to discuss specific cases or
        confidential information. If, during the discussions we hear
        people providing such information we may interrupt and ask them
        to make their comments more general.

# PRESENTATION

**Dr. Berkowitz**:

Today's presentation will focus on the ethical questions raised when
patients refuse to have house officers or residents participate in their
care.

This topic came to our attention through the Ethics Center's
consultation service, when a VA facility requested a consult about a
patient who demanded to "opt out" of being seen by trainees. The patient
was receiving care in a VA clinic where patients are first seen by
residents to complete initial paperwork and exams prior to each being
seen by the attending. This procedure is the most efficient for the
facility, and gives residents the experience they need to become
competent practitioners. This particular patient, however, did not want
to complete his initial paperwork and exams with a resident; he wanted
to be seen only by attending-level physicians. The facility felt that
residents were appropriately supervised and were not performing
activities beyond their competence, and while they generally try to
honor patients' requests regarding choice of providers, this request
seemed unreasonable because it would potentially limit other patients'
access to attending physicians.

The literature suggests that patient requests to limit the involvement
of house staff and trainees is not that uncommon. Joining me on the call
today to investigate the ethics of such requests is Joel Roselin. Joel
is a Program Specialist at the National Center for Ethics in Health
Care, and has a background in philosophy and ethics. Prior to joining
the Ethics Center, Joel was Director of Public Programs at the Harvard
Medical School Division of Medical Ethics.

Joel, before we go into the ethics of patients' refusal of care by house
officers and trainees, can you give us a sense of how often patients
actually make this type of request?

**Mr. Roselin**:

This is certainly not a new or unique situation. I think we all know of
instances where such a request has been made, but just how often is
difficult to say. Few studies have documented actual requests, and most
of the data, some of which I'll talk about in a moment, examined
patients *attitudes* about being cared for by trainees, rather than
their actual *willingness*. In a paper published last year in the
*Journal of the American College of Surgery*, Dutta and colleagues sent
a mail survey to all members of the Association for Program Directors in
Surgery \[Dutta S, Dunnington G, Blanchard MC, Spielman B, DaRosa D,
Joehl RJ. \"And doctor, no residents please!\" *Journal of the American
College of Surgeons* 2003;197(6):1012-7. Available at:
<http://www.journalacs.org/article/PIIS1072751503009505/fulltext>.(Requires
online account)\]. They received responses from 305. Respondents
reported a mean average of 13 requests per year for exclusion of house
staff from operative cases (range 0 to 100), an average of 1 request per
year for exclusion from ward rounds (range 0 to 60), and an average of 2
requests per year for exclusion of medical students from clinic (range 0
to 30). This was a study of surgical programs and I am not aware of any
similar studies of other types of residency programs.

**Dr. Berkowitz**:

That gives us at least some indication of how often patients refuse care
by house officers and trainees, but what makes that an ethical concern?

**Mr. Roselin**:

At the root of the question of whether or not patients should be able to
opt out of being seen by trainees is an ethical tension, namely, patient
autonomy to make treatment decisions vs. the social benefit of educating
physicians and other health care professionals, and the health care
system's obligation to provide care efficiently. Under patient autonomy
we can identify three specific rights that come into play: the right to
refuse treatment, the right to select physician (within certain limits);
and the right to be informed about known risks and benefits, potential
complications, and professional competency. On the other side of the
equation we have two critical factors: health care is a societal benefit
that is shared by all, and medicine can only be practiced and, to a
certain extent, learned on living patients. The challenge posed by the
patient who asks to opt out is that both of these are critical values
for our society. Patients have a right to make decisions about their
care, but without a system for adequately training new professionals, no
one will have access to quality care.

**Dr. Berkowitz**:

In addition, our system is simply not designed or staffed in a way that
affords all care to be provided by attendings.

So it is in the nature of the VA, and really of all teaching hospitals,
that there is dual mission: that of providing quality care to our
patients while educating the next generation of health care
professionals. Again, this is a critical issue for VA, since VA plays a
crucial role in medical education in this country, with upwards of 50%
of all clinicians training at a VA facility at some point in their
careers.

The next question to ask is, Why do you suppose patients want to opt out
of receiving care from house officers and trainees? I think it has to do
with the obvious assumption that being cared for by trainees is not as
safe as being cared for by more experienced professionals. Is there any
data to support this?

**Mr. Roselin**:

The question is: Are patients cared for by trainees at increased risk?
And the impression is that they must be. One would have to assume that
unpracticed clinicians make more mistakes, because that is in the nature
of learning any new set of skills. This has led to the idea of the
so-called "July phenomenon," the belief that you don't want to be in the
hospital in the month of July when the new batch of residents and
students begin, and all the other trainees are promoted into new
responsibilities. Studies that address this issue have not demonstrated
a positive relationship between house staff inexperience and adverse
events on the wards, which may be due to increased supervision during
that time. While trainees will inevitably make mistakes, the literature
shows that supervised mistakes do not lead to increased adverse
outcomes. Additionally, many people believe, albeit anecdotally, that
patients actually benefit from the increased time and attention they
receive from residents and students.

**Dr. Berkowitz**:

How can we assure that patients are not at increased risk?

**Mr. Roselin**:

The simple answer is supervision -- trainees do not act alone. The
medical writer, Atul Gawande, himself a surgical resident in Boston, has
written about the challenges of training on patients. In his 2002 book,
*Complications: A Surgeon**\'s Notes on an Imperfect Science*
\[Metropolitan Books, New York: 2002\], he noted: "In medicine, there
has long been a conflict between the imperative to give patients the
best possible care and the need to provide novices with experience.
Residencies attempt to mitigate potential harm through supervision and
graduated responsibility."

The VA is very clear that trainees are supervised on all procedures
until they have demonstrated proficiency. This is what Gawande referred
to as "graduated responsibility." VHA Handbook 1400.1, *Resident
Supervision*, defines graduated responsibility this way:

> "As part of their training program, residents should be given
> progressive responsibility for the care of the patient. The
> determination of a resident's ability to provide care to patients
> without a supervising practitioner present, or to act in a teaching
> capacity is based on documented evaluation of the resident's clinical
> experience, judgment, knowledge, and technical skill. Ultimately, it
> is the decision of the supervising practitioner as to which activities
> the resident will be allowed to perform within the context of the
> assigned levels of responsibility. *The overriding consideration must
> be the safe and effective care of the patient that is the personal
> responsibility of the supervising practitioner*" \[emphasis added\].

**Dr. Berkowitz**:

That last statement makes it clear that attending physicians must
reinforce the ethical imperative that the overriding consideration
should be safe and effective patient care. It is our obligation to make
it clear to our trainees that if there is any doubt, they should seek
assistance. If residents get mixed messages or are given unclear
expectations from supervising physicians regarding when it is
appropriate to ask for assistance they may be confused about their
primary ethical obligation to the safe and effective care of the
patient.

But even if we make it clear to our trainees, how much do patients
really understand about the way medical education works and the various
roles of the people who care for them in the teaching hospital?

**Mr. Roselin**:

I think many of us in medicine may have unreasonable expectations about
just how much patients understand. In a study published in *Academic
Medicine* in February 2004, Sally Santen and colleagues interviewed
patients at Vanderbilt University Medical Center Emergency Department to
test the hypothesis that "Patients may be unaware that physicians who
have not completed their training or medical students may be delivering
a large portion of their care" \[Santen SA, Hemphill RR, Prough EE,
Perlowski AA. Do patients understand their physician\'s level of
training? A survey of emergency department patients**.** *Acad Med*
2004; 79:139-143. Available at:
<http://www.academicmedicine.org/cgi/content/full/79/2/139>. (Requires
online account)\]. Prior research had indicated to them that patients
have limited understanding of the different training levels within the
medical education system. Santen et al. surveyed 430 adult patients in
an ER setting to determine knowledge and attitudes regarding physicians'
levels of training. Eighty percent "felt that it was important to know
the level of training of the physicians caring for them, but only 58%
felt that they actually knew their training level. This disparity
suggests that physicians and students may not be clearly identifying
themselves to their patients in their initial introductions. However,
even when this introduction is made, the patient may not understand what
a specific title means. Although 91% of participants appeared to
understand that students, interns, and residents are all at different
levels of training, further understanding of the different roles and
responsibilities of these providers was limited." In another study of
202 ER patients published concurrently, Santen et al. found that sixty
percent of respondents did not realize that he or she could be the first
person on whom a resident performs a procedure. They concluded that, "It
should not be assumed that patients coming to a teaching hospital know
they will be cared for by physicians-in-training."

**Dr. Berkowitz**:

I think it is often assumed in teaching hospitals that patients are at
least aware of the different training levels of practitioners providing
their care. Is it because physicians are so familiar with the inner
workings of the hospital that they fail to communicate that effectively
or accurately to patients who are probably less familiar?

**Mr. Roselin**:

A paper in the *Journal of Clinical Ethics* on patients' willingness to
participate in medical education by Peter Ubel (from the VA Medical
Center in Ann Arbor) and Ari Silver-Isenstadt (from the University of
Maryland) found that "previous studies have reported that many medical
schools and medical students are hesitant to identify medical students
to patients. One study reported that many medical schools do not clearly
identify medical students on their nametags. Another study found that 65
to 75 percent of internal medicine and pediatric departments in medical
schools do not inform patients that medical students will perform
invasive procedures such as lumbar puncture, bone marrow aspiration or
paracentesis. The same study also reported that 5 percent of
chairpersons of OB/GYN departments advise students to introduce
themselves as physicians to patients" \[Ubel PA, Silver-Isenstadt A. Are
patients willing to participate in medical education? *Journal of
Clinical Ethics* 2000; 11(3):230-5\].

Now why would they do that? Some studies have indicated that medical
students and faculty do not always inform patients about their training
status due to a fear that the patients might refuse to allow trainees to
participate in their care. Santen et al. wondered whether there is a
"purposeful 'conspiracy of silence' because we don't want to deal with
the repercussions of a fully informed patient who may refuse to allow a
physician-in-training to participate in their care."

**Dr. Berkowitz**:

So some studies suggest that more could be done to inform patients about
the role of trainees in their care, and not doing so limits their
ability to make a fully informed decision about their willingness to
participate. But are the fears of refusal justified? Do we have any data
to indicate how willing patients are to participate in training if they
are fully informed?

**Mr. Roselin**:

The news is generally positive. Almost universally, patients want to be
informed and asked about participating in education. In a study cited by
Ubel, investigators reported that 100 percent of patients wanted to be
asked whether they would allow students to participate in their care
rather than have students simply assigned to them. A secondError:
Reference source not found study by Santen of 202 patients on their
willingness to allow residents to practice new procedures on them, most
patients felt they should be informed if it was the resident's first
time performing a procedure and most would agree to it. If they knew
that they were a resident's first attempt at the procedure, only 8% said
they would refuse suturing, 27% said they would refuse intubation, and
52% said they would refuse lumbar puncture. If they were the resident's
tenth patient, 6% said they would refuse suturing, 15% intubation and
36% lumbar puncture. Interestingly, Santen found that despite many
participants not realizing they might be the first patients on whom a
resident performs a procedure, nearly all (97%) felt the current method
of teaching residents is appropriate \[Santen SA, Hemphill RR, McDonald
MF, Jo CO. Patients\' willingness to allow residents to learn to
practice medical procedures. *Acad Med* 2004; 79:144-147. Available at:
<http://www.academicmedicine.org/cgi/content/full/79/2/144>. (Requires
online account)\].

In Ubel'sError: Reference source not found study of 100 patients, they
found that respondents' willingness to interact with medical students in
the outpatient settings varied, depending upon the procedure. Only 2%
said they would definitely or probably refuse to allow a medical student
to take their blood pressure, and 7% would refuse to let a student take
a medical history. However, 36% said that they would definitely or
probably refuse to let a medical student perform a rectal examination,
and 39% would definitely or probably refuse a pelvic exam; 78% would
definitely or probably refuse to allow a medical student to perform a
spinal tap.

In one study cited by Dutta of 200 surgical inpatients surveyed, "90%
wished to contribute to resident education, yet a third of the patients
did not want residents involved in their operation, and most of the
remainder \[those who were not averse to resident participation\] would
allow the resident to perform only small parts of the procedure."

So the bottom line may be that enough patients are willing to
participate in training that we need not fear asking for their consent.
As Ubel noted, "Patients are generally willing to interact with medical
students in a variety of specific clinical settings, but their
willingness varies depending on the setting. Patients have a right to
information about when they are interacting with students, thus
preserving their right to refusal. Such openness would not have dire
consequences for medical education. Enough patients say that they are
willing to interact with medical students to allow students to learn.
Just as significantly, enough patients say they would refuse interaction
with medical students that we need to heed their request for informed
consent."

As part of the education process we want to train clinicians to
recognize and be respectful of patients' options and choices. After all,
we are role models for our trainees and students.

**Dr. Berkowitz**:

There seems to be a consensus that it is ethically appropriate to tell
patients if they are to interact with or be care for by trainees. Are
there any formal standards or guidelines on this topic?

**Mr. Roselin**:

When I began looking into this topic, I was surprised to find out that
there in fact have been guidelines on this going back several decades.
To a greater or lesser extent, these policies have identified the
patient's right to be informed about trainees caring for them as well as
their right to opt out of such training programs. In 1973 the Department
of Health, Education and Welfare issued a report which recommended that,
"The patient who is about to enter a \[teaching hospital\] should be
told fully what to expect.... Upon admission he should be given a
statement explaining the educational aims and activities of the
institution and told how students, interns, and residents will
participated in his \[or her\] care" \[U.S. Department of Health,
Education, and Welfare, *Report of the Secretary\'s Commission on
Medical Malpractice*. U.S. Government Printing Office, Washington,
D.C.:1973\].

In 1985 the Joint Commission on Accreditation of Hospitals (now the
JCAHO) promulgated guidelines that said: "The patient has the right to
know the identity and professionals status of individuals providing
service to him.... This includes the patient's right to know of the
existence of any professional relationship...to any...educational
institutions involved in his care. Participation by patients in clinical
training programs should be voluntary" \[Comprehensive Accreditation
Manual for Hospitals 2004, Standard RI.2.60\].

And in 2000 the AMA issued their own recommendations which state:
"Patients should be informed of the identity and training status of
individuals involved in their care, and all healthcare professionals
share the responsibility for properly identifying themselves....
Patients are free to choose from whom they receive treatment. When
medical students are involved in the care of patients, health care
professionals should relate the benefits of medical student
participation to patients and should ensure that they are willing to
permit such participation" \[Council on Ethical and Judicial Affairs of
the American Medical Association. Medical students\' involvement in
patient care. *Journal of Clinical Ethics* 2001; 12(2):111-5., see also
American Medical Association Code of Medical Ethics E-8.087, Medical
Student Involvement in Patient Care. Available at:
<http://www.ama-assn.org/ama/pub/category/8491.html>\].

**Dr. Berkowitz**:

One of the problems with these guidelines, I would say, is that they
privilege patient decision making above all else and they provide little
guidance for the concern expressed by our case consult, namely that to
eliminate residents and other trainees from the care of a particular
patient may unduly interfere with the smooth running of the hospital or
clinic and may compromise other patients' access to attending
physicians. Do you have any suggestions on how facilities should address
these concerns when they arise?

**Mr. Roselin**:

Yes. An article from our Ethic Center's newsletter addressed this
subject in the Summer/Fall 2002 issue. Here's what it suggested for
addressing these requests:

> "Although VHA informed consent policy states that patients have the
> right to refuse any medical treatment or procedure offered to them,
> the policy does not comment on whether patients have a right to demand
> treatments that are not offered or modifications to treatments that
> are offered. Nor does the VHA resident supervision policy specifically
> address patient requests to exclude medical trainees from their care.
> For VHA, respect for patient preferences is an explicit goal. However,
> respect for patient preferences does not mean that all patient demands
> must be honored. While patients have the right to refuse any
> recommended medical care, they do not necessarily have the right to
> dictate that care be delivered in a particular fashion" \[Patient
> refusal of care by a trainee. News@Vhaethics Newsletter. Summer/Fall
> 2002. Available at:
> <http://www.va.gov/vhaethics/newsletter/2002-2/ethicsrounds5.cfm>\].

**Dr. Berkowitz**:

So, to what extent should a physician or health care system be expected
to alter the usual care provided in order to accommodate a patient's
request?

**Mr. Roselin**:

Requests should be honored whenever possible, but there is no obligation
to honor unreasonable requests. Requests for deviations from usual care
may be refused for one of several reasons. First, such requests should
be refused if they would require the physician or the health care system
to participate in care that is inappropriate or substandard or if they
would likely do more harm than good. Requests for deviations from usual
care may also be refused if they would require a change in the system of
care that would unfairly consume staff time or resources or otherwise
interfere with the care of other patients.

In the case at hand, the request for exclusion of medical trainees from
a patient's care is, on the face of it, not unreasonable. However, for a
facility that relies on medical trainees for day-to-day patient care,
fulfilling such a request might require the facility to alter not just
the care of this one patient, but its overall system of care. In
particular, it may not be feasible for the facility to replace all of
the functions normally performed by medical students, interns, and
residents with attending physicians, nurses, and other health care
professionals. The facility might not be able to fulfill this patient\'s
request without unduly burdening the system or compromising the care of
other patients. If that were the case, the attending physician and VHA
would be justified in denying the patient\'s request.

**Dr. Berkowitz**:

What should an attending physician do when faced with a request to
exclude trainees from care?

**Mr. Roselin**:

First, the attending should attempt to understand the patient\'s
rationale. Gathering and clarifying facts to ensure a mutual
understanding between physician and patient is essential. If the patient
is concerned about medical trainees\' skill, the attending physician
could explain VHA's commitment to quality and tell them that residents
are granted increasing responsibility commensurate with their training
and experience to ensure that patients receive care only from those with
the necessary knowledge and skill. The attending physician might also
inform the patient about research evidence indicating that compared with
non-teaching hospitals, teaching hospitals are associated with higher
quality health care and lower mortality rates. Presenting and explaining
this information may help relieve the patient\'s concerns.

**Dr. Berkowitz**:

It seems that this is really an issue of arming patients with the facts
and reassuring them, and we may need to do a better job of informing
patients before we can get their consent.

**Mr. Roselin**:

I would say that's the key. Up to now, however, opting out has tended to
be a privilege granted to those who were in the know, those connected
with the hospital, such as health care professionals and their families.
This creates a secondary ethical problem: a question of justice, or of
sharing the risks as well as the benefits of the system. Atul Gawande,
the author and surgical resident described his experience this way:

> "When an attending physician brings a sick family member in for
> surgery, people at the hospital think twice about letting trainees
> participate. \[Even when the attending insists that they participate
> as usual, the residents scrubbing in know that it will be far from a
> teaching case. And if a central line must be put in, a first-timer is
> certainly not going to do it.\] Conversely, the ward services and
> clinics where residents have the most responsibility are populated by
> the poor, the uninsured.... Residents have few opportunities nowadays
> to operate independently, without the attending docs scrubbed in, but
> when we do -- as we must before graduating and going out to operate on
> our own -- it is generally with these, the humblest of patients."

In closing I would just say that if we are to be ethical in balancing
the dual mission of providing quality patient care while educating
health care professionals, the policies must be transparent and they
must be applied uniformly to all patients.

# MODERATED DISCUSSION

**Dr. Berkowitz**:

Thank you for that analysis, Joel. Now I would like to open up the phone
lines to our listeners, and see if anyone has reactions or comments to
what we said.

**Dr. Alan Sooho---Chief of Staff, Battle Creek, MI VAMC:**

Do you have any comments about house staff practicing on newly deceased
patients?

**Dr. Berkowitz:**

In fact, that was a topic of a recent National Ethics Teleconference,
available on our website at:
<http://www.va.gov/download/NET11.19.03.doc>.

**Lori---Lincoln, NE VAMC**:

Do you have any information about how lack of sleep can affect trainees
and residents, especially during their emergency room rotation?

**Mr. Roselin**:

There have been a number of studies looking at errors caused by sleep
deprivation, which led ACGME to issue new guidelines last year limiting
resident hours, and trying to maximize the amount of down time to
prevent untoward events happening, as well as preserve the general
health of our trainees.

There are a few studies that try to quantify the effects of sleep
deprivation. Studdert and Brennan published several papers on the topic
within the last few years \[For example, Gawande AA, Zinner MJ, Studdert
DM, Brennan TA. Analysis of errors reported by surgeons at three
teaching hospitals. *Surgery* 2003; 133(6):614-21. Available at:
<http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=home&id=SY>.
(Requires online account)\] as well as Lucian Leape from the Harvard
School of Public Health \[For example, Leape LL, Berwick DM, Bates DW.
What practices will most improve safety? Evidence-based medicine meets
patient safety. *JAMA* 2002; 288(4):501-7. Available at:
<http://jama.ama-assn.org/cgi/content/full/288/4/501>.(Requires online
account)\].

The greatest accumulation of knowledge available on the topic, however,
is in the 1999, the Institute of Medicine issued a report called, "To
Err is Human," which examined the larger issue of error in the medical
context \[Institute of Medicine. *To Err is Human: Building a Safer
Health System*. The National Academies Press, Washington, DC: 1999.
Available at: <http://www.iom.edu/report.asp?id=5575>\].

**Dr. Berkowitz**:

The issue of sleep deprivation is another balancing act: balancing
quality care versus the way we treat employees versus the way we deliver
care. I think it almost goes without saying---and I'm glad you brought
it up---that residents have to be in a work environment where they
function up to their potential.

**Lori**:

I wasn't aware of the new guidelines, but part of the problem is that
this is an income for residents and trainees as well, so we hate to turn
that down.

**Mr. Roselin**:

Well, you actually hit one of the secondary problems even with the ACGME
guidelines, which is people going beyond their assigned responsibilities
and moonlighting. But the ACGME has attempted to address that problem as
well in the new guidelines.

**Dr. Williams---North Little Rock, AK VAMC**:

I think we need to be careful not to misrepresent to the patient the
actual level of training a resident or trainee has. Some trainees are
appropriately skilled, but other trainees maybe have not yet performed
the procedure, so we need to say that they will be appropriately
supervised, not that they are appropriately skilled.

**Dr. Berkowitz**:

I certainly agree that we would never want to overstate or misrepresent
trainees' level of expertise, and if, in a particular situation, the
trainee is being appropriately supervised, then that should be what we
communicate. Do you have specific feelings about that?

**Dr. Williams**:

I do in that I do not want to give misinformation or encourage
misperception by our patients. I think one of the worst things we can do
as clinicians is say something in a way that causes patients to doubt
what we say in the future. There is always the risk we will
inadvertently misrepresent the situation in the way we phrase it, and I
just wanted to be sure that people were thinking through the appropriate
language, and tailoring the discussion to the specific situation.

**Dr. Berkowitz**:\
\
I agree with you that the main point of this discussion is clear
disclosure and honest communication with patients. The best way to
promote good communication is to tailor our conversations with patients
to their specific clinical circumstances.

**Mr. Roselin**:

While I wouldn't presume to give you the actual language to talk with
your patients, I would refer you to the Santen articles from the July
2004 issue of *Academic Medicine*. They found that while people
certainly wanted to know if it was a trainee's first time performing a
procedure, in most cases patients would still consent to treatment. Part
of what we have tried to express, and what the literature bears out, is
that we need not and should not be afraid to give people the facts and
the details of the situation for fear that they will refuse care, and
that our residents and students will be denied practice time with
patients.

**Beverly Lane---Patient Advocate, Chicago VAMC**:

We have run into the issue of patients refusing care by residents not
because of the patient's particular concern with the resident's
competence, but because their insurance will only cover clinic visits
with an attending physician. If they receive care from a resident, the
insurance company will not cover the clinic visit.

What is your recommendation about that particular issue?

**Alice Fields---Brooklyn, NY VAMC**:

In our experience, if the attending documents proper supervision of the
resident, the clinic visit will be covered by the insurer. The problem I
see with that practice, however, is that sets up a dual standard of
care, because the patient who has to co-pay either has to be seen by an
attending, or has to have maybe more complete documentation by the
attending in order not to be charged for it, while patients who do not
have to co-pay can be seen by residents without a high level of
supervision or documentation by the attending.

**Dr. Berkowitz**:

So it seems there are ways to modify the billing and coding to satisfy
insurers without unduly burdening the system, but that is beyond my
level of expertise. You may want to take that up with your MCCR, and CCF
people, and it may be a question that you want to ask your local ethics
committee out in Chicago.

**Sandy Stone---West Los Angeles, CA VAMC**:

I am a utilization review nurse, and I do billing. Under current billing
guidelines we cannot use documentation from the medical student for
billing purposes, but we can bill if the attending signs the resident's
notes, or the resident notes that the he has discussed the case with the
attending. In no way do the current billing guidelines dictate who a
patient needs to see in order for the insurer to cover that visit, but
we do make clear that the resident has to document that the attending is
supervising him.

**Dr. Berkowitz**:

What Sandy brought out is a great point, and Joel brought it up too,
which is that there are some differences between students and residents.
Residents have a much higher level of expertise, and are often licensed
practitioners. So there are going to be differences in the way this
applies to students versus other trainees.

What other concerns have come up in the field about the responsibilities
of trainees and residents?

**Ms. Lane**:

There is always a great deal of confusion and concern about the
attending's responsibilities and the resident's level on confusion in
writing DNR/DNI orders. We have rotating staff coming through who do not
know our DNR/DNI policy, and so they do not know that the attending
physician is responsible for signing or monitoring everything that is
happening with a patient who requests a DNR/DNI order. It is clear to us
that we need to have very aggressive training for our house staff on
these particular issues.

**Dr. Berkowitz**:

As an attending physician, it is important to keep in mind that we are
responsible for the care of the patient, and for appropriately
supervising the house staff. We, in a sense, give out that graduated
level of responsibility, and the burden of that is squarely upon the
supervisors.

**Bonnie Fairchild---Wilmington, DE VAMC**:

I am a member of our ethics committee, and we had a consult from the
intensive care unit about a person who had been brought in after a heart
attack. The patient had a living will, and could not talk. He was
intubated, and his proxy said, "he never wanted to be intubated. Take it
out." The physicians said that because the patient was not in a terminal
condition, they could not remove the breathing tube. What kind of
training can we do that will help physicians realize that proxies are
the ones who make decisions for patients when they cannot do so
themselves?

**Dr. Berkowitz**:

I agree with you that the essential concepts in cases like these are
respect for the patient's right of self-determination, either through
their previously stated wishes, or through their surrogate. Not only
that, but there is no requirement for terminal illness in the current
DNR policy.

**Ms. Fields**:

I also wanted to add that just because a patient cannot talk does not
mean that the patient cannot decide. So you have to be very careful in
those situations to make sure the patient has the opportunity to decide
for him or herself.

**Ms. Fairchild**:

Fortunately he was extubated and is doing fine, so the question resolved
itself, but we are concerned about what education we need to be
providing to the young physicians coming into the VA system.

**Dr. Berkowitz**:

The house staff should not be making those kinds of decisions about
whether to extubate a patient. That is clearly an attending level
decision, and critical decisions need to be made at the appropriate
level and by the appropriate supervisor.

**Dr. Ellen Fox---National Center for Ethics in Health Care, Washington,
DC**:

I just wanted to jump in on a couple of points that were discussed
earlier. First, on the question relating to billing, I recommend that
you involve the compliance office in your facility. This is a really
complicated issue, and I believe that there have been some changes
lately, and that's really their area of expertise, and they would be
able to address that. The second point is on residents writing DNR
orders. We received a lot of questions about that about a year ago, and
there was a lot of confusion on that issue, and so we actually issued
clarification, and that's available on our website at:
<http://vaww.va.gov/vhaethics/download/EthicsRx(DNRProtocols)5.6.03.doc>.

**Dr. Smith---Memphis, TN VAMC**:

I think there might be a problem if we pose to patients that they can
state a preference about whether or not to involve trainees in their
health care. In our system we cannot really honor their preference if
they want to opt out of care by trainees, and that puts patients in an
awkward situation, because then we are giving the choice of my way or
the highway.

**Dr. Berkowitz**:

I think you are right that there are limits to what requests we can
practically honor, but we do at least need to tell patients what they
are getting into when they enter the VA system, which includes receiving
care by residents and trainees. If they have no other options, at least
they will be aware of how they will receive care in VA, and if they have
the option of another health care system, maybe they will vote with
their feet. This is potentially analogous to health care systems that
have specific restrictions on treatments concerning beginning of life
issues. While we do not expect all hospitals to provide the full range
of services because of strong moral feelings, that does not mean that we
do not want patients to understand their options so that if they wanted
to pursue another option, and it was within their power, they couldn't
go and seek care elsewhere. So, I do think that disclosure and
transparency is, honestly, the best policy.

**Mr. Roselin**:

I would have to agree with that assessment, and say that while all the
policies that I quoted in my presentation have one thing in common,
which is informing the patient, they do not point to the notion that
patients must therefore consent to each interaction with residents. The
AMA proposals I quoted, are for medical students, and the AMA, as far as
I know has not promulgated a position on the same question with regard
to residents. However, they do say in that policy about students that we
need to inform patients upon entry into the hospital that they will be
seen by students, residents, interns, and attending physicians. I think
that regardless of whether you can give patients the option to opt out
of certain interactions, you must give them the information about who
they will be seen by, so we are not making any prescriptions about how
care must be provided, or writing any policy, but it is uniformly agreed
that patients are entitled to the knowledge that they are in a teaching
environment, and to be given a basic understanding of what that means
for their care.

**Dr. Fox**:

I think we said earlier that if a patient makes a reasonable request,
that we should make reasonable accommodations. There are some requests
that are reasonable, and might not affect other patients' care, in which
case we would try to accommodate them.

# FROM THE FIELD

**Dr. Berkowitz:**

Now I want to turn to our "From the Field" segment, where we take
comments from our listeners on ethics topics [not]{.underline} related
to today's call. Please remember, no specific consultation requests in
this open format, but I invite you now to make your comments on other
ethics-related topics, or to continue our discussion on whether patients
should be Able to Refuse Care by House Officers or Trainees?

**Dr. Mark Graber---Northport, NY VAMC**:

I would like to ask a question related to the previous discussion, and
it has to do with a statement that was made at the start about patients'
right to select their own physician. Does that right still exist, do you
think, for a patient who selects the VA, which is not really a
physician, but a health care system?

**Dr. Berkowitz**:

To be honest with you, that might be the topic of another call.

**Unknown**:

We have a problem generally in the VA system with waiting times. That's
primarily a health care issue, but that can be an ethical issue when we
have people that are waiting maybe six months waiting for an
appointment, and then a dire condition is discovered at their first
appointment.

**Dr. Berkowitz**:

There has been a tremendous effort throughout our system to reduce
waiting times. As a system, we have made real progress in dramatically
reducing wait times. If you know of place where that continues to a
problem, I urge to bring it the appropriate local or VISN resources to
address it.

**CONCLUSION**

**Dr. Berkowitz:**

Well, as usual, we did not expect to conclude this discussion in the
time allotted, and unfortunately we are out of time for today\'s
discussion. We will post on our Web site a very detailed summary of each
National Ethics Teleconference. So please visit our Web site to review
today\'s discussion. We will be sending a follow up email for this call
that will include the links to the appropriate web addresses for the
call summary, the CME credits, and the references referred to.

I would like to thank everyone who has worked hard on the development,
planning, and implementation of this call. It is never a trivial task
and I appreciate everyone\'s efforts, especially, Joel Roselin, Nichelle
Cherry, and other members of the Ethics Center and EES staff who support
these calls.

-   Let me remind you our next NET call will be on Tuesday, April 27^th^
    at noon EST. Please look to the Web site at vaww.va.gov/vhaethics
    and your Outlook e-mail for details and announcements.

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    Center, the summary of this call and the instructions for obtaining
    CME credits, and the references that I mentioned.

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-   Please let us know if you or someone you know should be receiving
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-   Again, our e-mail address is:
    [vhaethics@hq.med.va.gov](mailto:vhaethics@hq.med.va.gov?subject=National Ethics Teleconference).

-   Thank you and have a great day!