Ethics of bedside clinics

Teaching at the bedside is a time-tested and traditional method of instilling the basics of medical practice in students. In fact every medical student looks forward to “clinics at the bedside.” The students see clinical signs, hear murmurs and palpate organs with excitement and enthusiasm. The teachers in turn demonstrate disease manifestations with zing and zeal. It is here that basic clinical skills as well as “bedside manners” are acquired by the students. Each patient is a chapter of a medical text book to be written in the grey matter of the student.

Let us imagine ourselves in a typical case discussion at a teaching hospital. The day before the class there is a frantic search for “good cases”. Once the “case” is identified, the presenter moves to the “case” and starts asking for details of his or her illness. Then he or she is examined, exposing parts of the chest or abdomen. The patient is asked to twist, turn and obey various commands to make the physical examination complete. More often than not, the willingness of the patient to be part of the class the next day is not requested. Once history taking and examination are accomplished, the batch mates come in twos and threes and repeat this procedure, despite protests and signs of non-cooperation from the afflicted individual. This kind of prior preparation for the class happens in the general ward, with no screen or curtain to maintain some privacy. The class follows the next day, where the entire process is repeated. Full length discussions on the different diagnoses, treatment options and prognosis are heard by the patient who is obviously anxious to gather any detail of his illness. Ardent discussions and conversations about complications and causes of death go on. Everyone, including the presenter and the teacher enjoys the class, ignoring the fact that some patients may be well versed in the English language.

While respecting the basic rights of all human beings, “autonomy” affirms the right of every individual to determine what shall be done to his/her body. The word autonomy originates from the Greek word for self rule. Autonomy is one of the four basic principles of medical ethics, affirming that the choice of a patient with regard to his/her therapy should be respected by the treating physician. Confidentiality in a doctor patient relationship also stems from the patient’s right to autonomy. This has been emphasised equally in the ancient medical codes of Hippocrates and Charaka as well as in the modern day ethical codes of the World and Indian Medical Councils.

Textbooks of medicine and clinical methods in medicine acknowledge and honour the above rights of patients as human beings. History taking and physical examination together is considered the beginning of a doctor-patient relationship. Hutchison’s clinical methods states that clinical skills are grasped during a lifetime of practice (1). The authors demand that students treat patients with sensitivity and gentleness, causing only minimal disturbance. Self introduction and statement of purpose should be done at the beginning of examination (2). It is also recommended that permission be sought to conduct physical examination (1). Adequate privacy should be maintained by means of a screen and conversation should be in low tones to prevent others from hearing the interview. When a male doctor examines a female patient, and vice versa, a chaperone is recommended. It is stated that presentations may be embarrassing for the patient and so the students are asked to be “kind, thoughtful and brief”. Subsequent discussions which cause unwanted anxiety to the patient should be avoided in his/her presence (3). Widely accepted textbooks of medicine like those of Harrison and Davidson also reiterate the importance of good communication and respect for the patient’s dignity all through a doctor’s interaction with a patient (4, 5). The Latin word patiens, from which “patient” has originated means “sufferance” or “forbearance”. It is the duty of the physician not to cause any further distress or discomfort to the patient.

Let us extend the principles of autonomy and confidentiality to these classes so that ethics begins at the patient’s bedside.