Abstract
Although many studies have explored the experiences of doctors in their first postgraduate year, few have focused on the ethical issues encountered by this group. Based on an extensive literature review of research involving house officers, we argue that these doctors encounter a broad range of‘ everyday’ ethical challenges, from truth-telling to working in non-ideal conditions. We propose a typology of house officers' ethical issues and advocate prioritizing these issues in undergraduate medical ethics and law curricula.
Introduction
Although many studies have explored the experiences of doctors in their first postgraduate year, 1-3 few have focused on the ethical issues encountered by this group. Traditionally called ‘house officers’, they are now referred to as F1 in the UK and ‘interns’ in North America and Australia. In this paper, we propose a typology of house officers' ethical challenges based on an extensive literature review and examine the implications of our classification for medical training. We adopt a broad definition of what counts as an ethical issue. Following bioethicist Soren Holm, in the context of this paper an ethical consideration refers to:
‘a) a non-legal or not solely legal norm, duty, obligation or
right; or b) consequences (well-being, happiness etc.) for some specifiable
person or groups of persons; or c) what kind of person one ought to be or what
virtues one ought to have.’
4[85]
Methodology
Sociologists, and particularly ethnographers, have long been interested in medical internship. 5,6 Studies of postgraduate medical training offer fascinating insights into the processes of professionalization and the moral development of junior doctors. 7,8 As medical education and the organization of internships evolve with time and as our primary concern was to develop a typology of ethical challenges faced by today's house officers, we chose to focus on recent research. We defined, rather arbitrarily, recent research in this area as work published from 1994 onwards.
To construct the typology, we identified relevant publications using three major electronic databases: Web of Science, Medline and Philosophers' Index. In Web of Science and Medline, the search terms used were ‘intern’ and ‘resident’, constructed inclusively (to capture, for example,‘ internship’). Articles from non-Western settings or published before 1994 were excluded. Searches were also conducted using the term‘ ethics’ together with ‘junior doctor’ and‘ house officer’ to ensure that relevant literature was not being over-looked due to terminological differences between countries. The search in Philosophers' Index used the term ‘intern or resident’ (again constructed inclusively) together with ‘ethics’ (or‘ ethical’) and ‘medicine’ (or ‘medical’). Much of the literature did not explicitly aim to investigate ethical issues, but was nonetheless relevant in understanding the ethical challenges faced by house officers.
A typology of ethical challenges
The work of Rosenbaum et al. served as the starting point for our typology. 9 Based on in-depth interviews with thirty-one junior doctors in their first, second or third postgraduate year, these authors suggested five categories of ethical conflict faced by junior doctors:
concern over telling the truth respecting patients' wishes preventing harm managing the limits of one's competence and addressing performance of others perceived to be inappropriate.
We drew on the literature review to construct a more comprehensive typology of the ethical challenges faced by house officers.
Table 1 presents eight broad ethical issues, with more specific examples in the second column. Some of the examples transcend several categories. For example, making mistakes could fall under ‘preventing harm’, ‘conflicts of interest’ and‘ managing the limits of one's competence’. As the typology is derived from existing research, its scope is limited to aspects of house officers' experiences that have already been studied; further ethical issues may emerge as more empirical research is conducted with this group.
The brief summaries below elaborate on some of the issues in Table 1. Since the aim of this paper is to present a systematic overview of ethical issues, rather than propose solutions to them, we do not attempt to analyse or resolve the problems. We leave this daunting task to the ethicists and educators.
Telling the truth
Like all doctors, house officers experience truth-telling dilemmas. However, their unique position in the medical hierarchy and their dual roles as clinician and learner bring additional problems. Should they tell patients about their lack of experience? Is it acceptable to stretch the truth with superiors to save face? Some house officers deceive consultants about figures or tasks they are expected to know or perform.10,11[279] In one study, 14% of participants (doctors in their first, second or third postgraduate year) indicated that they were likely to fabricate a laboratory value to a consultant to avoid being humiliated. 10 House officers may also lie to colleagues, such as radiographers or laboratory technicians, about a patient's condition in order to obtain tests ordered by a consultant.11[281-2]
Respecting patient autonomy
To respect patient autonomy, doctors must provide information without manipulation or coercion. In one study, nearly a third of junior doctors reported intentionally influencing patients to accept or reject procedures. 12 On occasion, junior doctors struggle to respect patients' wishes about treatment: while they may be aware of the patients' wishes, they may be unable to respect them when their superiors are unreceptive to the patient's requests. 13[59] Finally, house officers can breach patient confidentiality, often inadvertently, by disclosing information without the patient's permission or by looking at the medical notes of hospitalized friends or colleagues. 12,14
Preventing harm
House officers' duty of non-maleficence (avoiding net harm to patients) can be difficult to fulfil when involving patients in the educational process. Furthermore, inexperienced house officers can be distressed by intrusive procedures and adverse patient outcomes, even when the treatment was necessary and competently performed. 9
Managing the limits of one's competence
Many house officers report being asked to perform tasks which they deem beyond their clinical competence. 1,3,15 Some also report difficulties around accessing support from more senior doctors due to a variety of factors, including superiors' work-loads, absence on leave or unwillingness to assist, as well as house officers' fear of verbal abuse or disapproval. 3,13 This could lead to negative outcomes for patients, particularly when a house officer's limited competence is coupled with inadequate supervision. The stress experienced by house officers can also be considerable; as newly qualified professionals, some feel ill-prepared for their responsibilities and struggle to cope. 13,16,17 These difficulties can be compounded by the absence of role models to serve as moral and practical guides. 14
Addressing the inappropriate behaviour of others
Some house officers will suspect or know that a doctor's competence is compromised or that a colleague's behaviour is unethical. 18 Dealing with this knowledge can be morally distressing, particularly in the context of house officers' dependence on their superiors for assessment and career advancement. How should house officers handle conflicts between their own beliefs and the views or demands of their superiors? How should they behave if they hear colleagues making inappropriate comments about patients?
Conflicts of interest
Questions arise about the appropriateness of house officers treating and giving medical advice to their friends, their relatives or themselves. There are also moral issues around accepting gifts and hospitality from drug companies.
Setting interpersonal boundaries with patients
Junior doctors report difficulties around negotiating the appropriate level of empathy, compassion and involvement with their patients. This is perhaps unsurprising given the erosion of compassion often associated with medical school (sometimes referred to in the literature as ‘ethical erosion’). 19,20 Issues relating to treating disliked, aggressive or infectious patients and dealing with patients' sexual advances or romantic intentions also fall under this category of‘ boundaries’. 21,22
Impact of working conditions
House officers tend to rotate jobs or placements every few months. The lack of stability and the emphasis on efficiency can contribute to a lack of reflection and empathy, and an undue deference to authority. 23 Transience also has a negative impact on house officers' personal lives, creating social isolation and making it difficult to pursue interests outside medicine. Furthermore, the long working hours, although more reasonable than in times past, can adversely affect their personal lives and, in turn, patient care. Some junior doctors feel unsupported by hospital administration. 3,24 They feel dissatisfied with arrangements for covering absent or sick colleagues. House officers may thus feel obliged to work even when unwell, with potentially negative consequences for their own well-being and the quality of patient care.
Conclusion
The typology shows the wealth of ethical challenges faced by house officers. To deal adequately with these challenges, house officers and medical students should receive appropriate and problem-specific training at the undergraduate level and during the first years of clinical practice. The issues in Table 1 tend to fall within what has been called the ‘ethics of the ordinary’ rather than the more dramatic ethical problems which, although fascinating, may be far removed from the realities of life as a house officer. 25 Although the proposed core curriculum in medical ethics and law in the UK incorporates several of the issues identified in our typology, it also includes topics such as the ethics of the new genetics and aspects of resource allocation which are of secondary importance to most medical students. 26 We suggest that undergraduate medical ethics curricula, necessarily constrained by the demands of other subjects, should give priority to the real-life issues that students will encounter in their first years of practice. A strong emphasis on the types of ethical problems we have described, rather than the classic bioethical dilemmas, would best equip graduates for the challenges of life as a junior doctor. Our typology can serve as a useful resource for teachers of medical ethics and law and for educators involved in curriculum development.
Footnotes
DECLARATIONS