To the Editor:
Peer physical examination (PPE) is an established experiential learning method in which students use fellow students as surrogate patients to learn clinical skills. However, students may feel pressured to participate despite discomfort and embarrassment.1 Obtaining students' informed consent to participate in PPE is an important way to reduce these disadvantages. Braunack-Mayer2 suggests that the extensive guidelines that promote free and informed consent to participate in research could be used to address the disadvantages associated with participation in PPE. She identifies similarities in ethical issues that arise in recruiting students to participate in research and in requiring or expecting students to participate in PPE.
However, we suggest there are some important differences. The goals of research are to produce generalizable scientific knowledge rather than to necessarily benefit or educate the potential participant.3 As a consequence, informed consent is directed toward sufficiently informing research participants about what is involved in their voluntary participation. In contrast, the goals of teaching clinical skills via PPE are to increase students' experiential knowledge and to enhance their ability to practice competently and sensitively with their future patients. We suggest that the process of obtaining patients' informed consent in clinical practice—rather than the process of obtaining participants' informed consent in research—provides a more comprehensive and relevant model for students who are learning clinical skills via PPE.
In clinical practice, ethical obligations to obtain patients' informed consent include an information component and a requirement to enhance the patient's capacity to make and participate in health decisions.4 Patients depend on information from their health practitioner, and students depend on information from their teacher. Both of these relationships are qualitatively different from the relationship of the researcher and research participant. The process of informed consent in both teaching and practice is a fiduciary one and is more than what Emanuel and Emanuel5 termed “the informative model.”
With the above considerations in mind, we suggest that obtaining informed consent from students for PPE should encompass broader clinical components of communication, such as providing information about both risks and benefits of learning via PPE, and an opportunity for students to ask questions, express their concerns, and request alternative learning approaches where possible. Informed consent for PPE should be a process that will provide students a model to apply when obtaining informed consent from their future patients.
Clare Delany, PhD, MHlth & Med Law, MPhysio
Senior lecturer, University of Melbourne, Melbourne, Australia, and clinical ethics fellow (allied health), Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Australia; [email protected].
Helena Frawley, PhD
National Institute of Clinical Studies (NH&MRC) fellow and senior lecturer, University of Melbourne, Melbourne, Australia.
1 Chang EH, Power DV. Are medical students comfortable with practicing physical examinations on each other? Acad Med. 2000;75:384–389. http://journals.lww.com/academicmedicine/Fulltext/2000/04000/Are_Medical_Students_Comfortable_with_Practicing.20.aspx
. Accessed January 5, 2011.
2 Braunack-Mayer AJ. Should medical students act as surrogate patients for each other? Med Educ. 2001;35:681–686.
3 Litton P. A normative justification for distinguishing the ethics of clinical research from the ethics of medical care. J Law Med. 2005;33:566–574.
4 Delany C. Making a difference: Incorporating theories of autonomy into models of informed consent. J Med Ethics. 2008;34:e3.
5 Emanuel EJ, Emanuel LL. Four models of the physician–patient relationship. JAMA. 1992;267:2221–1226.