Recently the new medical school at Florida State was held hostage by
hospitals for potential for liability cost even though in the entire state
of Florida involving 4 medical schools over many decades only 3 medical
students have been involved in adverse events. The unrealistic liability
climate in Florida was largely to blame for the concerns by hospitals, but
this is but one example of the barriers involved in getting the kind of
experience needed to be a better physician.
Although it is important for students to follow established procedures for
volunteers to minimize problems (high school, college, medical school,
etc.), the risks are minimal in all scenarios. The hospitals have
established protocols to follow in case of injury. If they do not have
them, students should not volunteer there. An orientation procedure should
be a part of every volunteer effort. Student organizations should spearhead
efforts to be sure of these areas.
I am not a lawyer, but if the "volunteering" were required as a part of
university functions, there is some potential for university liability.
This is why making sure that students use the right facilities and follow
established procedures is important.
There is a caveat in America today: You can always face legal action.
The question that to me is more important: Will you be disabled by the
threat of legal action, even if the probability is very low? Will those
that reach out most to others be the ones most crippled by the threat of
legal action? Will our leaders fail to have experience in the future
because we failed to help them take those first critical steps to take some
relatively small risks?
Previously I have noted that one of the major problems facing the medical
profession is the loss of service orientation.
Best Vs Brightest Almost as deadly is the
increasing inability of students and residents at all levels to be able to
make decisions and care for patients. This is directly related to the lack
of responsibility given to them for care of patients. Fears of liability
loom large in both of these realities. How long can we go before we realize
how much it costs us for us to have to train doctors years after graduation
from medical school and residency?
The ones who suffer most are the patients, particularly the most complex
ones, those in most need of care. The underserved need more than just a
medical approach. They need a population-family-multidimensional-culture-based approach. It is my feeling that until medical students understand
medicine, they will not go the extra mile to learn about community
medicine, prevention, culture, doctor-patient relationships, etc. My
feelings are supported by recent AAMC GQ findings that these same areas are
rated as most inadequately taught by medical schools.
In medical studies some 15 years ago in the midst of another liability
crisis, doctors were asked why they stopped delivering babies. The top
reason that they gave was liability concerns. Further studies pointed out
that restoring liability access and cost barriers did not restore
obstetrical interest in the physician. The real problem is that liability
concerns were an excuse for doctors who did not have to deliver babies
anymore (better finances, salaried not productivity, older and with kids of
their own to raise) to get out of the hassles of call and poor
reimbursement and teen pregnancy and several other complex issues going on
at the time.
It is not my intent to minimize a most serious question with serious
potential problems.
It is my intent to motivate those who truly care for students and student
organizations to help them go the extra mile to protect the students and
institutions so that we can continue and expand service orientation in this
nation.
If we truly want to resolve the current global crises regarding people with
no hope, we must encourage the students who can most restore this hope to
rise up and volunteer and serve and learn to lead and teach. The
underserved in this nation would be a good place to start.
I must also expose my bias. I do rural medical education programs. In AAMC
GQ studies of those interested in choosing towns of less than 10,000, they
were twice as likely to do rural experiences, international missions or
experiences, or local volunteer work when compared to their medical student
peers. I feel that the more we pick those who volunteer and serve, and the
more we encourage these efforts, the more we will have in underserved rural
and urban communities in this nation and other nations.
Rural Interested Students
If we go the other way and trust students more and give them more
responsibility, we also have an idea of the outcome. We have a track of
students at UNMC that accelerates and becomes a first year resident during
their M-4 year. Basically this gives them patient care-decision making
opportunities one year early. These students also know as an M-3 that they
are headed to rural underserved locations. By their second year of
residency they are moving beyond the usual boundaries, having mastered
medicine to a degree greater than their peers. The twenty-four graduates
have demonstrated that they are a different breed who go out and serve: 60
% are in towns of less than 5000, one is already physician-leader at AAFP,
and one just signed a contract to serve in a small town but reserved 3
months a year to do missions in Africa.
This program is a great end point, but I would be quick to point out that
the real success of the program is another story. These students were
identified before admissions by a dean of admissions who works closely with
the small colleges in the state. These students were encouraged by their
advisors, they managed to survive the admissions process, they served
during medical school, they were given opportunities to advance their
medical training, they enhanced this training with weekend moonlighting,
and they have continued to serve with their careers.
Robert C. Bowman, M.D, Co-Chairman
Rural Medical Educators Group of the National Rural Health Association
UNMC Department of Family Medicine Director of Rural Health Education and
Research
983075 Nebraska Medical Center
Omaha, NE 68198-3075
(402) 559-8873 or fax at -8118
Email: rbowman@unmc.edu
http://www.unmc.edu/Community/ruralmeded/
"... nothing to fear but fear itself."
To echo Dr. Bowman's excellent comments, the service aspects of a health
career are key factors for the success of that career. That has been true
in the past and will be even more important in the future. How can our
advisees be confident of a professional life built around these principles
unless they have sampled them in the discernment process? Not to encourage
these service activities because of fear of suits would be like advising
them to be Olympic swimmers without ever getting in the pool because there
could be alligators in there!
In the Research Associates (RA) programs that I have directed over the last
six years in two inner city emergency departments, more than 500 college
students from around the country have participated. There has never been a
lawsuit or even mention of a suit. RAs receive the same safety training
that all hospital volunteers and employees have before starting patient
contact. Part of my introduction to this part of their training emphasizes
that choosing a career in the health professions entails relative risk.
"You are, after all, choosing to be around people who are sick. To care for
them during your career, you may breath the same air. You may use sharp
instruments that have been in contact with your patients before potentially
cutting you. Their body fluids are often splattered near you. The chances
for personal illness, minute as they are if you take the prescribed
precautions that you will be taught, are still greater than you will likely
encounter in an office or a classroom. Make an informed decision that you
are willing to accept that small, but relatively greater risk before
agreeing to the lifetime commitment of a health career."
I will be the first to admit that my stance is easy to take since there are
no pending suits. I hope that my conviction would withstand the test of
litigation. Without patient care exposure early on in their discernment,
how else can our students know that being of service will be fulfilling for
their lives. They will be better doctors (or not doctors) from the
experience. I can think of worse things for which to be sued.
Keith
Keith Bradley, MD, FACEP
Health Sciences Advisor
Health Professions Preparation Program (HP3)
203 254 4000 x 3238
kbradley@mail.fairfield.edu
Dr. Bradley:
Thanks for your input - it was an excellent addition to previous posts. I concur
- in 25+ years of providing clinical and didactic education for Allied health
students (numbering in the 1,000s) both in the US and internationally I can
identify only 2 incidents where students/observers were harmed by patient
contact or connected activities. Each of these resulted from a lack of attention
to safety precautions.
I was particularly impressed with your statement of relative risk. I wonder if
you would permit me to adopt this statement for use in my own presentations
with, of course, appropriate attribution?
"You are, after all, choosing to be around people who are sick. To care for
them during your career, you may breath the same air. You may use sharp
instruments that have been in contact with your patients before potentially
cutting you. Their body fluids are often splattered near you. The chances for
personal illness, minute as they are if you take the prescribed precautions that
you will be taught, are still greater than you will likely encounter in an
office or a classroom. Make an informed decision that you are willing to accept
that small, but relatively greater risk before agreeing to the lifetime
commitment of a health career."
Paul Mathews
Paul Mathews PhD, RRT, FCCM, FCCP
Associate Professor Resp Care
University of Kansas Med Ctr.
913-588-4630 (V) 913-588-4631 (F)
I hate to keep on harping on this topic, but the comments that I have
been reading lately on this listserve have repeatedly talked about
medical training. If all we continue to do in medicine is train
people and not educate them, we will be in more serious trouble in the
future. Training is not enough. Most information that people in the
medical profession need today they can very easily access, generally
on the computer and internet. Training only involves giving people
information and showing them techniques. What makes anyone believe
that a person you can "ape" something (i.e., regurgitate information)
is intelligent or for that matter capable. Being able to regurgitate
facts definitely doesn't give them the ability to think and solve
problems. All college graduates, and more so for those going into
medical fields, must be able to think and solve problems. This can
only come from education. Maybe if our students would be better
educated and not just trained, we wouldn't have to have this
discussion on volunteerism and liability. Bob Stach
Robert W. Stach, Ph.D.
Professor
Department of Chemistry
University of Michigan-Flint
Flint. MI 48502
Phone: 810-762-3111
E-Mail: bobstach@umflint.edu
Our pre-medical students take Clinical Preceptorship during the school year
for academic credit. As such, they are covered by the college's insurance policy
for any accident / illness that might befall them when they are on the health
care provider's premises.
Joseph H. Lechner, Ph.D.
Professor of Chemistry
Mount Vernon Nazarene College
800 Martinsburg Road
Mount Vernon, OH 43050-9500
[740] 397-9000 extension 3211
Education - the entire pipeline