Appendix 2a - Taps

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

When it comes to doing invasive procedures like spinal taps, the majority of 1500 medical students surveyed (63%) seldom or never obtained specific permission.[25] At the same time, "72% of patients indicated they would be upset to find out they had been the unsuspecting subject of a novice's first spinal tap."[26] Another study with 1600 medical students found the same result; when asked, "Do you specifically ask permission as a medical student to perform invasive procedures [like spinal taps]?" Fifty-six percent said "Never."[27]

The doctors don't ask permission either. Only 4-6% of clinical departments in the country specifically inform patients that the medical student will actually "push the needle" for invasive procedures like spinal taps. Only about 1 out of 20 hospitals obtain consent.[28]

What about spinal taps performed on children? Sixty-five percent of the chairs of pediatrics departments across the country surveyed self-reported that they do not inform the patients or parents that students are actually doing the procedure. That means most pediatric departments in the country are involved in this unethical and arguably illegal practice. From Academic Medicine: "Although this is, of course, understandable from the student's perspective, it seems particularly perverse with respect to the patient's interests."[29] Quoting from one of the researchers involved in these studies, "Patients admitted to teaching hospitals do not... by the mere act of admission relinquish their human rights...."[30]

"Beginning one's career lying to patients is hardly a strong ethical foundation."[31]

One survey of patients found that 70% of patients were not informed of the students' status,[32] but what if they were? Even if one does find a physician respectful enough of human autonomy to actually 1) explain the risks of a procedure, 2) tell the patient who's doing it and 3) ask permission, a number of potential problems still remain.

First of all, what if the doctors themselves don't know the risks involved? More specifically, what if you tested the knowledge of family physicians and general surgeons about the risks associated with common surgical and invasive diagnostic procedures? This is what researchers found:

Only 27% of the total risk estimates fell within the order of magnitude reported in the literature.... For every complication, many physicians made underestimation or overestimation errors by several orders of magnitude and a few consistently denied existence of any risk.... [For example] substantial percentages of physicians underestimated the risk of death due to [hernia repair]... by a factor of 100 or even 1000.[33]

Secondly, the patient has to understand that they have the right to say no. In a survey of patients in a general internal medicine practice, a third of the patients preferred not to have medical students participating in their care.[34] But do they feel in a position to refuse? In one Swedish study, 46% of patients who had medical students involved in their care agreed with the statement, "I understood that medical students were present but did not feel that I had any possibility of declining to participate."[35]

And finally, the doctors and students have to keep their end of the bargain. What if the patient specifically refuses to give consent; do students honor their wish? In one study, medical students were presented with a situation in which their chief resident asks them to perform an intubation on a sedated patient awaiting surgery. The student is told that the patient had earlier specifically informed the medical team that she did not want students to perform any procedures on her. Despite this, 30% of the students said that they would have "definitely or probably intubated the patient" if this situation had actually occurred during their clinical rotation anyway.[36]

The barber learns his trade on the orphan's chin - Arabic Proverb

The problem is not limited to medical students. What if a resident has little or no experience performing a particular procedure? How many residents in a national survey intentionally chose to not inform a competent patient of their inexperience? Sixty-two percent (243/389). For 29% this wasn't even considered an ethical dilemma. For those who were aware that what they were doing was wrong, excuses for their actions included, "to avoid looking bad," and a quarter said it was because they were, "imitating the behavior of role models."

More on such dilemmas in Appendix 2b.


[26] Williams, CT and N Fost. "Ethical Considerations Surrounding First Time Procedures." Kennedy Institute of Ethics Journal 2(1992):217-231.

[27] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part II." Proceedings of the Annual Conference on Research on Medical Education 24(1985):146-153.

[28] Ibid.

[29] Silverman, DR. "Narrowing the Gap between the Rhetoric and the Reality of Medical Ethics." Academic Medicine 71(1996):227-235.

[30] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part I." Proceedings of the Annual Conference on Research on Medical Education 24(1985):138-145.

[31] Marracino, RK and RD Orr. "Entitling the Student Doctor." Journal Of General Internal Medicine 13(1998):266-270.

[32] Barnes, HV, M Albanese and J Schroeder. "Informed Consent." Journal of Medical Education 55(1980):699-703.

[33] Kronlund, SF and WR Phillips. "Physician Knowledge of Risks of Surgical and Invasive Diagnostic Procedures." Western Journal of Medicine 142(1985):565-569.

[34] Simons, RJ, E Imboden and JK Martel. "Patient Attitudes toward Medical Student Participation in a General Internal Medicine Clinic." Journal Of General Internal Medicine 10(1995):251-254.

[35] Lynoe, N, et al. "Informed Consent in Clinical Training - Patient Experiences and Motives for Participating." Medical Education 32(1998):465-471.

[36] Feldman, DS, et al. "The Ethical Dilemma of Students Learning to Perform Procedures on Nonconsenting Patients." Academic Medicine 74(1999):79.

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