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The authors of this letter are currently engaged in revising “Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand”.[[1]] We disagree with Dr Gray’s[[2]] proposal that the consensus statement[[1]] is flawed. Gray argues the consensus statement is couched in ethical terms that prioritise patient autonomy, which is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[3]] The quadruple aim encompasses improving population health, patient experience, healthcare team wellbeing and reduced costs.[[3]] What Gray does not acknowledge is the Code of Health and Disability Services Consumers' Rights,[[4]] as set out in the Health and Disability Commissioner Act 1994,[[5]] is the law in Aotearoa New Zealand. Thus, the consensus statement on medical students and informed consent was written to reflect the law in the most pragmatic way possible. In particular, Right 6, the “right to be fully informed”, and Right 7, the “right to make an informed choice and give informed consent”.

We make no apology for supporting patient autonomy in the consensus statement. Patients have an ethical and legal right to understand “who, how and why” will be engaged in their healthcare—particularly if it is for learning. Gray does not acknowledge the distinction made in the consensus statement between involvement of students primarily for the benefit of their education, and involvement that may occasionally be necessary for the care of patients, such as when a qualified clinician is unavailable at a cardiac arrest. Doctors have an ethical and legal duty to ensure patients and their whānau are fully informed to the extent practicable in the circumstances. A student’s need to be educated does not trump this duty. Patients should understand what their healthcare will involve, by whom and for what purpose, and have an input into these decisions. Such informed shared decision making will result in better patient outcomes, reduced costs, improved population health, patient experience and team wellbeing—the process of obtaining consent, done well, is consistent with the quadruple aim of quality medical practice and has the potential to enhance it.

Informed consent encompasses much more than the alternative term “agreement” proposed by Gray. Consent is a word commonly used in both professional and lay settings and has meaning. Informed consent, rather than just assent, must be gained by supervising clinicians for student involvement in teaching. It encompasses the nuances involved in both patient and whānau agreement to patients engaging in student learning—this naturally will be influenced by the relationship the clinician has with the patient and their whānau. As is stated in the consensus statement, informed consent is an ongoing process that patients can withdraw at any stage, however, agreement is simply an outcome of a discussion.

Gray makes two factually inaccurate comments. First, that in requiring students to obtain consent for teaching, the CS recommendations are asking students to do something not required of graduate doctors. Indeed, this requirement for informed patient consent when trainees are involved in the provision of patient care has been unequivocally reinforced in Health and Disability Commissioner opinions.[[6,7]] Second, Gray suggests that while the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings. However, it is registered healthcare professionals, not students, who are required to obtain consent for teaching and any aspect of patient care. Students instead have the responsibility to ensure that consent has been obtained. Within the apprenticeship model, healthcare professionals can and should provide opportunities for medical students to learn and demonstrate informed consent, but this doesn’t negate the responsibility for consent that lies with the healthcare professional.

We agree that greater attention should have been paid to cultural safety within the consensus statement. Doctors essentially hold the power in the doctor–patient relationship and must consider how this reflects on the way they engage with the patient.[[8]] It is important for doctors and medical students to reflect on the impact of their own culture and attitudes, and not to impose their own values onto patients and their whānau. The consensus statement is currently being revised to ensure that cultural safety in Aotearoa is properly encompassed in the consent process. The principles of patient and whānau involvement and autonomy remain central. Good communication with a focus on doctors reflecting on their own views and biases is a vital part of the consent process—not separate to it, and it doesn’t negate the need for consent. The days of applying health and teaching of health to patients without their understanding and consent are gone. This outdated approach is simply not acceptable within current medical education frameworks or practice, or within New Zealand law as reflected by the HDC code of patient rights. A recent publication from the University of Auckland[[9]] indicates that consent for student involvement in teaching by patients can and is being obtained well for most patients in obstetrics and gynaecology. However, the results for patient consent for medical student teaching in other sensitive exams are disappointing, and the reports of students being coerced into conducting sensitive exams on patients without consent is deeply concerning.[[9]] We can and must do better, even in busy, rushed clinical environments.

In summary, apart from the important matter of cultural safety, we disagree with Gray and think that all clinicians in Aotearoa can uphold the law, which in this matter we also believe to be ethically appropriate.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sarah C Rennie: Clinical Skills Director, Deans Department, University of Otago, Wellington. Lynley Anderson: Head of Department, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Alan F Merry: Faculty of Medical and Health Science, The University of Auckland. Suzanne Pitama: Dean and Head of Campus, University of Otago, Christchurch. Papaarangi Reid: Tumuaki Deputy Dean Māori, Head of Department, The University of Auckland. Jeanne Snelling: Senior Lecturer, Faculty of Law, University of Otago, Dunedin. Simon Walker: Senior Lecturer, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Tim Wilkinson: Deputy Dean, Education Unit, University of Otago, Christchurch. Warwick Bagg: Deputy Dean, Faculty of Medical and Health Sciences, University of Auckland.

Acknowledgements

Correspondence

Sarah C Rennie: Deans Department, University of Otago, Wellington, PO Box 7343, Mein St, Newtown, Wellington 6242.

Correspondence Email

sarah.rennie@otago.ac.nz

Competing Interests

Nil.

1) Bagg W, Adams J, Anderson L, Malpas P, Pidgeon G, Thorn M, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. N Z Med J. 2015 May 15;128(1414):27-35.

2) Gray B. Consent for teaching. N Z Med J. 2022 Jul 1;135(1557):64-69.

3) Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.

4) Health and Disability Commissioner. Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996.

5) Health and Disability Commissioner Act 1994.

6) Health & Disability Commissioner. Radiologist did not obtain consent for registrar to observe ultrasound at teaching hospital (00HDC06794). 2001. Available at: https://www.hdc.org.nz/media/2582/00hdc06794casenote.pdf. Accessed Jul 26, 2022.

7) Health & Disability Commissioner. Complication during eye surgery (13HDC01345). 2015. Available at: https://www.hdc.org.nz/media/2041/13hdc01345casenote.pdf. Accessed Jul 26, 2022.

8) Te Kaunihera Rata o Aotearoa Medical Council Zealand. Statement on cultural safety. 2019.

9) Bhoopatkar H, Campos CFC, Malpas PJ, Wearn AM. Adherence to a national consensus statement on informed consent: medical students’ experience of obtaining informed consent from patients for sensitive examinations. N Z Med J. 2022 May 20;135(1555):10-18.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The authors of this letter are currently engaged in revising “Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand”.[[1]] We disagree with Dr Gray’s[[2]] proposal that the consensus statement[[1]] is flawed. Gray argues the consensus statement is couched in ethical terms that prioritise patient autonomy, which is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[3]] The quadruple aim encompasses improving population health, patient experience, healthcare team wellbeing and reduced costs.[[3]] What Gray does not acknowledge is the Code of Health and Disability Services Consumers' Rights,[[4]] as set out in the Health and Disability Commissioner Act 1994,[[5]] is the law in Aotearoa New Zealand. Thus, the consensus statement on medical students and informed consent was written to reflect the law in the most pragmatic way possible. In particular, Right 6, the “right to be fully informed”, and Right 7, the “right to make an informed choice and give informed consent”.

We make no apology for supporting patient autonomy in the consensus statement. Patients have an ethical and legal right to understand “who, how and why” will be engaged in their healthcare—particularly if it is for learning. Gray does not acknowledge the distinction made in the consensus statement between involvement of students primarily for the benefit of their education, and involvement that may occasionally be necessary for the care of patients, such as when a qualified clinician is unavailable at a cardiac arrest. Doctors have an ethical and legal duty to ensure patients and their whānau are fully informed to the extent practicable in the circumstances. A student’s need to be educated does not trump this duty. Patients should understand what their healthcare will involve, by whom and for what purpose, and have an input into these decisions. Such informed shared decision making will result in better patient outcomes, reduced costs, improved population health, patient experience and team wellbeing—the process of obtaining consent, done well, is consistent with the quadruple aim of quality medical practice and has the potential to enhance it.

Informed consent encompasses much more than the alternative term “agreement” proposed by Gray. Consent is a word commonly used in both professional and lay settings and has meaning. Informed consent, rather than just assent, must be gained by supervising clinicians for student involvement in teaching. It encompasses the nuances involved in both patient and whānau agreement to patients engaging in student learning—this naturally will be influenced by the relationship the clinician has with the patient and their whānau. As is stated in the consensus statement, informed consent is an ongoing process that patients can withdraw at any stage, however, agreement is simply an outcome of a discussion.

Gray makes two factually inaccurate comments. First, that in requiring students to obtain consent for teaching, the CS recommendations are asking students to do something not required of graduate doctors. Indeed, this requirement for informed patient consent when trainees are involved in the provision of patient care has been unequivocally reinforced in Health and Disability Commissioner opinions.[[6,7]] Second, Gray suggests that while the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings. However, it is registered healthcare professionals, not students, who are required to obtain consent for teaching and any aspect of patient care. Students instead have the responsibility to ensure that consent has been obtained. Within the apprenticeship model, healthcare professionals can and should provide opportunities for medical students to learn and demonstrate informed consent, but this doesn’t negate the responsibility for consent that lies with the healthcare professional.

We agree that greater attention should have been paid to cultural safety within the consensus statement. Doctors essentially hold the power in the doctor–patient relationship and must consider how this reflects on the way they engage with the patient.[[8]] It is important for doctors and medical students to reflect on the impact of their own culture and attitudes, and not to impose their own values onto patients and their whānau. The consensus statement is currently being revised to ensure that cultural safety in Aotearoa is properly encompassed in the consent process. The principles of patient and whānau involvement and autonomy remain central. Good communication with a focus on doctors reflecting on their own views and biases is a vital part of the consent process—not separate to it, and it doesn’t negate the need for consent. The days of applying health and teaching of health to patients without their understanding and consent are gone. This outdated approach is simply not acceptable within current medical education frameworks or practice, or within New Zealand law as reflected by the HDC code of patient rights. A recent publication from the University of Auckland[[9]] indicates that consent for student involvement in teaching by patients can and is being obtained well for most patients in obstetrics and gynaecology. However, the results for patient consent for medical student teaching in other sensitive exams are disappointing, and the reports of students being coerced into conducting sensitive exams on patients without consent is deeply concerning.[[9]] We can and must do better, even in busy, rushed clinical environments.

In summary, apart from the important matter of cultural safety, we disagree with Gray and think that all clinicians in Aotearoa can uphold the law, which in this matter we also believe to be ethically appropriate.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sarah C Rennie: Clinical Skills Director, Deans Department, University of Otago, Wellington. Lynley Anderson: Head of Department, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Alan F Merry: Faculty of Medical and Health Science, The University of Auckland. Suzanne Pitama: Dean and Head of Campus, University of Otago, Christchurch. Papaarangi Reid: Tumuaki Deputy Dean Māori, Head of Department, The University of Auckland. Jeanne Snelling: Senior Lecturer, Faculty of Law, University of Otago, Dunedin. Simon Walker: Senior Lecturer, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Tim Wilkinson: Deputy Dean, Education Unit, University of Otago, Christchurch. Warwick Bagg: Deputy Dean, Faculty of Medical and Health Sciences, University of Auckland.

Acknowledgements

Correspondence

Sarah C Rennie: Deans Department, University of Otago, Wellington, PO Box 7343, Mein St, Newtown, Wellington 6242.

Correspondence Email

sarah.rennie@otago.ac.nz

Competing Interests

Nil.

1) Bagg W, Adams J, Anderson L, Malpas P, Pidgeon G, Thorn M, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. N Z Med J. 2015 May 15;128(1414):27-35.

2) Gray B. Consent for teaching. N Z Med J. 2022 Jul 1;135(1557):64-69.

3) Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.

4) Health and Disability Commissioner. Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996.

5) Health and Disability Commissioner Act 1994.

6) Health & Disability Commissioner. Radiologist did not obtain consent for registrar to observe ultrasound at teaching hospital (00HDC06794). 2001. Available at: https://www.hdc.org.nz/media/2582/00hdc06794casenote.pdf. Accessed Jul 26, 2022.

7) Health & Disability Commissioner. Complication during eye surgery (13HDC01345). 2015. Available at: https://www.hdc.org.nz/media/2041/13hdc01345casenote.pdf. Accessed Jul 26, 2022.

8) Te Kaunihera Rata o Aotearoa Medical Council Zealand. Statement on cultural safety. 2019.

9) Bhoopatkar H, Campos CFC, Malpas PJ, Wearn AM. Adherence to a national consensus statement on informed consent: medical students’ experience of obtaining informed consent from patients for sensitive examinations. N Z Med J. 2022 May 20;135(1555):10-18.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The authors of this letter are currently engaged in revising “Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand”.[[1]] We disagree with Dr Gray’s[[2]] proposal that the consensus statement[[1]] is flawed. Gray argues the consensus statement is couched in ethical terms that prioritise patient autonomy, which is inconsistent with the approach of balancing the quadruple aim of quality medical practice.[[3]] The quadruple aim encompasses improving population health, patient experience, healthcare team wellbeing and reduced costs.[[3]] What Gray does not acknowledge is the Code of Health and Disability Services Consumers' Rights,[[4]] as set out in the Health and Disability Commissioner Act 1994,[[5]] is the law in Aotearoa New Zealand. Thus, the consensus statement on medical students and informed consent was written to reflect the law in the most pragmatic way possible. In particular, Right 6, the “right to be fully informed”, and Right 7, the “right to make an informed choice and give informed consent”.

We make no apology for supporting patient autonomy in the consensus statement. Patients have an ethical and legal right to understand “who, how and why” will be engaged in their healthcare—particularly if it is for learning. Gray does not acknowledge the distinction made in the consensus statement between involvement of students primarily for the benefit of their education, and involvement that may occasionally be necessary for the care of patients, such as when a qualified clinician is unavailable at a cardiac arrest. Doctors have an ethical and legal duty to ensure patients and their whānau are fully informed to the extent practicable in the circumstances. A student’s need to be educated does not trump this duty. Patients should understand what their healthcare will involve, by whom and for what purpose, and have an input into these decisions. Such informed shared decision making will result in better patient outcomes, reduced costs, improved population health, patient experience and team wellbeing—the process of obtaining consent, done well, is consistent with the quadruple aim of quality medical practice and has the potential to enhance it.

Informed consent encompasses much more than the alternative term “agreement” proposed by Gray. Consent is a word commonly used in both professional and lay settings and has meaning. Informed consent, rather than just assent, must be gained by supervising clinicians for student involvement in teaching. It encompasses the nuances involved in both patient and whānau agreement to patients engaging in student learning—this naturally will be influenced by the relationship the clinician has with the patient and their whānau. As is stated in the consensus statement, informed consent is an ongoing process that patients can withdraw at any stage, however, agreement is simply an outcome of a discussion.

Gray makes two factually inaccurate comments. First, that in requiring students to obtain consent for teaching, the CS recommendations are asking students to do something not required of graduate doctors. Indeed, this requirement for informed patient consent when trainees are involved in the provision of patient care has been unequivocally reinforced in Health and Disability Commissioner opinions.[[6,7]] Second, Gray suggests that while the CS refers to the apprenticeship model, the requirement for consent for teaching runs counter to the use of this model in other settings. However, it is registered healthcare professionals, not students, who are required to obtain consent for teaching and any aspect of patient care. Students instead have the responsibility to ensure that consent has been obtained. Within the apprenticeship model, healthcare professionals can and should provide opportunities for medical students to learn and demonstrate informed consent, but this doesn’t negate the responsibility for consent that lies with the healthcare professional.

We agree that greater attention should have been paid to cultural safety within the consensus statement. Doctors essentially hold the power in the doctor–patient relationship and must consider how this reflects on the way they engage with the patient.[[8]] It is important for doctors and medical students to reflect on the impact of their own culture and attitudes, and not to impose their own values onto patients and their whānau. The consensus statement is currently being revised to ensure that cultural safety in Aotearoa is properly encompassed in the consent process. The principles of patient and whānau involvement and autonomy remain central. Good communication with a focus on doctors reflecting on their own views and biases is a vital part of the consent process—not separate to it, and it doesn’t negate the need for consent. The days of applying health and teaching of health to patients without their understanding and consent are gone. This outdated approach is simply not acceptable within current medical education frameworks or practice, or within New Zealand law as reflected by the HDC code of patient rights. A recent publication from the University of Auckland[[9]] indicates that consent for student involvement in teaching by patients can and is being obtained well for most patients in obstetrics and gynaecology. However, the results for patient consent for medical student teaching in other sensitive exams are disappointing, and the reports of students being coerced into conducting sensitive exams on patients without consent is deeply concerning.[[9]] We can and must do better, even in busy, rushed clinical environments.

In summary, apart from the important matter of cultural safety, we disagree with Gray and think that all clinicians in Aotearoa can uphold the law, which in this matter we also believe to be ethically appropriate.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sarah C Rennie: Clinical Skills Director, Deans Department, University of Otago, Wellington. Lynley Anderson: Head of Department, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Alan F Merry: Faculty of Medical and Health Science, The University of Auckland. Suzanne Pitama: Dean and Head of Campus, University of Otago, Christchurch. Papaarangi Reid: Tumuaki Deputy Dean Māori, Head of Department, The University of Auckland. Jeanne Snelling: Senior Lecturer, Faculty of Law, University of Otago, Dunedin. Simon Walker: Senior Lecturer, Bioethics Centre, Division of Health Sciences, University of Otago, Dunedin. Tim Wilkinson: Deputy Dean, Education Unit, University of Otago, Christchurch. Warwick Bagg: Deputy Dean, Faculty of Medical and Health Sciences, University of Auckland.

Acknowledgements

Correspondence

Sarah C Rennie: Deans Department, University of Otago, Wellington, PO Box 7343, Mein St, Newtown, Wellington 6242.

Correspondence Email

sarah.rennie@otago.ac.nz

Competing Interests

Nil.

1) Bagg W, Adams J, Anderson L, Malpas P, Pidgeon G, Thorn M, et al. Medical Students and informed consent: A consensus statement prepared by the Faculties of Medical and Health Science of the Universities of Auckland and Otago, Chief Medical Officers of District Health Boards, New Zealand Medical Students' Association and the Medical Council of New Zealand. N Z Med J. 2015 May 15;128(1414):27-35.

2) Gray B. Consent for teaching. N Z Med J. 2022 Jul 1;135(1557):64-69.

3) Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.

4) Health and Disability Commissioner. Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996.

5) Health and Disability Commissioner Act 1994.

6) Health & Disability Commissioner. Radiologist did not obtain consent for registrar to observe ultrasound at teaching hospital (00HDC06794). 2001. Available at: https://www.hdc.org.nz/media/2582/00hdc06794casenote.pdf. Accessed Jul 26, 2022.

7) Health & Disability Commissioner. Complication during eye surgery (13HDC01345). 2015. Available at: https://www.hdc.org.nz/media/2041/13hdc01345casenote.pdf. Accessed Jul 26, 2022.

8) Te Kaunihera Rata o Aotearoa Medical Council Zealand. Statement on cultural safety. 2019.

9) Bhoopatkar H, Campos CFC, Malpas PJ, Wearn AM. Adherence to a national consensus statement on informed consent: medical students’ experience of obtaining informed consent from patients for sensitive examinations. N Z Med J. 2022 May 20;135(1555):10-18.

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