Are our patient consent rules making it harder to train the next generation of doctors?
An article in The Conversation argues that the strict requirement for patients to content to the involvement of junior doctors in their care is hindering medical training.
Author and Associate Professor of Primary Health Care and General Practice at Otago University, Dr Ben Gray says it’s limiting hands-on learning, especially in critical situations.
He told Kerre Woodham the interpretation of the rules has narrowed over time, and doesn’t include situations where patients are unconscious or distressed.
Gray says it means students potentially won’t have the chance to learn about those patients and how to treat them, if they can’t get consent.
LISTEN ABOVE
See omnystudio.com/listener for privacy information.
Listen
Watch
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:06):
You're listening to the carry Wood and Morning's podcast from
News Talks.
Speaker 2 (00:10):
He'd be a piece in the conversation website caught my
eye this morning. It's from doctor Ben Gray, Associate Professor
of Primary Healthcare in General Practice at the University of Otago,
and he writes, new research is raising a pretty uncomfortable question.
Are our patient consent rules actually making it harder to
(00:30):
train the next generation of doctors? In New Zealand, junior
doctors often need explicit consent just to be involved in treatment.
Critics say that that's limiting hands on learning and could
be contributing.
Speaker 3 (00:43):
To our doctor shortage.
Speaker 2 (00:45):
So do we need to loosen the rules to make
sure doctors are getting properly trained? Dr Ben Gray joins
me now in a very good morning to you.
Speaker 1 (00:56):
Good morning, how are you very very well?
Speaker 2 (00:59):
Thank you. I remember when I was having my daughter,
the attending physician said, would you mind if a couple
of young trainees had to feel basically to see how
far along you are? And I was like, no, that's fine,
you know, because how else are you going to know
if a cervice is dilated unless you feel a cervix
(01:20):
that is dilated and there was no paperwork to fill
out or anything like that. Have things changed in recent times.
Speaker 3 (01:30):
Well, there are a couple of things to say. The
rules haven't changed so that the Health and Disability Commissions
Code of Patient Rights says that consent is consent for
teaching is required, But the interpretation of those rules has
been made narrower in the first place by the development
of a student Code of Practice, which is very explicit
(01:54):
that students shouldn't be involved with with learning with patients
unless they have consent. And the biggest problem with that
is not with the sort of scenario you're describing, where
you were conscious and alert and presumably not so distressed
that you were annoyed at having anyone else ask you anything.
The problem is with those patients who are unconscious or
(02:16):
who are distressed or whatever. And it means that the
potentially the students don't get an opportunity to learn about
those patients if they can't get consent, and that's what
the rules say. The other thing that happened was that
the commissioner, in response to a complaint in relation to
a registrar doing a procedure on a patient and consent
(02:37):
for teaching had not been gained for that, and she
made it clear that her view is that consent for
teaching applies not just to medical students but to postgraduate
doctors in training. And so this interpretation has narrowed it
down quite a lot, and I think is given the
context of how few doctors we have and the problem
(02:57):
we have with getting them trained, it's a constraint which
I think is really unhelpful.
Speaker 2 (03:04):
I just don't think, and I don't know because I've
never trained as a doctor. I don't even watch that
many medical shows on television, so I'm not a doctor
in training. But I would have thought that training on dummies,
no matter how lifelike they are, it doesn't prepare you
at all for the real thing.
Speaker 3 (03:24):
No, no, okay, it prepares you. It does prepare you.
And the example in the piece I wrote for the
Conversation was about how you learned to do CPR cardiofomary resuscitation.
And I mean anyone who's done a first aid course
will have seen the dummies that were used to train
people to do CPR, and they're useful. You know. It
means you've got an idea of what it's about. But
(03:45):
one of the things that I have is I get
reflective essays from students, and I've had numerous essays from
students describing their first CPR, where the thing they learned
was how to deal with the fact that you're trying
to help someone's life from you know, to help someone
from dying with relatives around who are acutely distressed, and
(04:06):
about whether you're good enough to do this. Yeah, and
without If you don't do your first CBR, you won't
learn that stuff. But the rules, if they were implemented
by the letter, would mean that no one would ever
learn CBR because you can't get consent from the patient
because they're unconscious of dying.
Speaker 2 (04:28):
Yeah. I remember years ago talking to a doctor, very
senior doctor had done his training at Guys in London
as a young trainee doctor, and they all trooped, about
ten of them trooped in for a woman who was
having a tonsils out. But they were able to give
her an internal examination because the only wombs and the
(04:51):
like that they had had experience on were fallen women.
This was back in the early sixties and they had
no idea what a healthy uterus was like, and because
no decent woman would allow that kind of exploration, they
did it well and more unconscious having other operations, So
we don't want that, do we know well?
Speaker 3 (05:11):
And the history of this is that that was effectively
what was happening in Wellington prior to the Cartwright inquiry.
In fact, my medical student cohort objected to being asked
to do our first vaginal examination on a woman who
wasn't aware that we were doing it because she was
anesthetized in theater. We objected to that. And what I'm
trying to say is that if this is just teaching,
(05:34):
so in that scenario the only thing the student is
doing is learning, they're not involved in the care whatsoever.
Then of course consent is required, you know, and it's
required for all sorts of purposes. But if, for example,
it were a student who was part of the orang
team who were doing a removal of a of a
(05:56):
uterus because of survival cancer, and prior to the procedure,
the student examined that woman to feel what it cat's
felt like. They're part of the team, that part of
the care provision, and I think requiring consent in that
setting it doesn't make any sense because why do we
get consent for the medical student to be there when
we don't get consent for the charge nurse or the
(06:17):
circulator nurse, or the anesthetic teams, all the other people
in theater, we're setting a standard for the medical students
which actually doesn't meet for everyone else's. Look, I understand
the you know, there are some costs here. It's not
it's it's unpleasant and more people doing this than is needed.
I understand that. But as you observe, if if we
(06:39):
don't learn how to examine what a cervix is like
when a baby's coming out, you never know when you're
going to be faced with that as a doctor, and
if you haven't done it before, you're not going to
be able to do a good job.
Speaker 2 (06:49):
And also, yeah, I suppose, but there I suppose there
are different values around bodies. Like I would have no
problem at all, and clearly didn't with trained professionals or
professionals in training using my body while I was making
(07:09):
use of their facilities, you know, making use of their
skills too, And I would still have no problem. Like
if anyone wanted a fossic feel free, you know, go ahead,
But I don't have any cultural hang ups around that.
And I guess that you have to take that into
account too well.
Speaker 3 (07:26):
And the point that I've made is that this is
the consent. Of course, we get consent. I mean, the
thing is that no one is involved in the care
of a patient who's conscious without their consent.
Speaker 1 (07:39):
Yeah.
Speaker 3 (07:39):
You know, either you made an appointment to come and
see me as a GP, or if I suggested you
see the practice nurse, you'll come in and say, oh,
I'm the practice nurse. I've come in to do your
blood sugar. Is that okay? It's part of normal practice
for everything that we get consent for involvement. Yeah, and
I think that we should just say, look, that's normal.
If the patient isn't conscious, you can't get consent for involvement.
(08:01):
And so the protection for patient safety and dignity is
the quality of the supervision. So someone is in control,
the senior clinician. And so in the setting I was
describing in theater where the student might examine a cancer
as cervix, that would be done under the supervision of
the specialist who would make sure that not too many
(08:22):
people did it, and would make sure that it was
done properly and with dignity, and you know, looked after
all of those features and then, of course, the thing
is that we can't consent everything we do because and
because we don't know what's going to happen, and so
during theater you might find an unexpected animality. You wait
the patient up and say, look, would you mind if
(08:43):
I operate on this as well while here. So the
whole model of consent as a way of securing patient
safety and dignity is a poor model for all of
those people who don't have capacity, So all the people
with dementia, all of the children who don't have their
parents present, all of the people in the wards who
are in distress and pain and who have lost capacity.
(09:06):
We don't learn on those with consent because they can't
give us consent.
Speaker 2 (09:10):
So you would you like to have an opt in
facility or an opt out solity?
Speaker 3 (09:17):
Well no, I think my view is that we need
to just reframe this as that. And part of this is,
so what's teaching anyway? And is there a difference between
teaching and learning And is it just students who learn
or teach or is it senior doctors as well? Of
course it's senior doctors as well. That all the surgeons
(09:38):
have learned new procedures since they've been consultant surgeons because
things have changed keyhole surgery for example, now so that
we're learning and teaching all the time. So I think
the idea, firstly that we need explicit consent for it
is it's problematic because of the issues that I've discussed.
So what I think more is that there's always an
(10:01):
opt out, because there's always if you look, if you
don't want me to care for you, then I won't
care for you. You know, this is a basic element
of the Bill of Rights that you can refuse medical treatment.
And that's what it should be with conscious patients, and
then with unconscious patients it should be on the basis
of say, high quality supervision and care and respect and
(10:21):
how you deal with the cultural differences. So, as a GP,
there would be some patients where I might have had
a student with me, and I'd be calling in someone
I thinking, uh, actually, I don't think i'll get the
student with this person because I knew some of the
circumstances of the particular distress or some of their cult values,
and I would, you know, just not call the student.
And so I'm not saying students should be there all
(10:42):
the time. I think the other important point is to
realize that having a student there improves your care. In
that I found as a GP, if the student was
sitting next to me, I was always second guessing, Oh
what would I say to the student? They asked me
why I did that? And they would know more about
the latest drugs and the latest literature because that's what
(11:02):
they've been studying. And so actually having a student as
part of the team means that you get better care overall.
And so I think we need to change the whole
culture in terms of you know, it's great that we've
got students. In fact, what I would like everyone on
your show to do is if they see their GP
in the next few weeks and they don't have a student,
ask them, oh, why don't you have a student? Brilliant?
Speaker 2 (11:26):
Thank you very much. Good to talk. That is doctor
being great, talking about getting more of our teachers, more
of our doctors, the opportunity to learn from doctor teachers
and to learn from the patient teachers.
Speaker 1 (11:41):
For more from Kerry Wood and Mornings, listen live to
news talks. It'd be from nine am weekdays, or follow
the podcast on iHeartRadio.
You're listening to the carry Wood and Morning's podcast from
News Talks.
Speaker 2 (00:10):
He'd be a piece in the conversation website caught my
eye this morning. It's from doctor Ben Gray, Associate Professor
of Primary Healthcare in General Practice at the University of Otago,
and he writes, new research is raising a pretty uncomfortable question.
Are our patient consent rules actually making it harder to
(00:30):
train the next generation of doctors? In New Zealand, junior
doctors often need explicit consent just to be involved in treatment.
Critics say that that's limiting hands on learning and could
be contributing.
Speaker 3 (00:43):
To our doctor shortage.
Speaker 2 (00:45):
So do we need to loosen the rules to make
sure doctors are getting properly trained? Dr Ben Gray joins
me now in a very good morning to you.
Speaker 1 (00:56):
Good morning, how are you very very well?
Speaker 2 (00:59):
Thank you. I remember when I was having my daughter,
the attending physician said, would you mind if a couple
of young trainees had to feel basically to see how
far along you are? And I was like, no, that's fine,
you know, because how else are you going to know
if a cervice is dilated unless you feel a cervix
(01:20):
that is dilated and there was no paperwork to fill
out or anything like that. Have things changed in recent times.
Speaker 3 (01:30):
Well, there are a couple of things to say. The
rules haven't changed so that the Health and Disability Commissions
Code of Patient Rights says that consent is consent for
teaching is required, But the interpretation of those rules has
been made narrower in the first place by the development
of a student Code of Practice, which is very explicit
(01:54):
that students shouldn't be involved with with learning with patients
unless they have consent. And the biggest problem with that
is not with the sort of scenario you're describing, where
you were conscious and alert and presumably not so distressed
that you were annoyed at having anyone else ask you anything.
The problem is with those patients who are unconscious or
(02:16):
who are distressed or whatever. And it means that the
potentially the students don't get an opportunity to learn about
those patients if they can't get consent, and that's what
the rules say. The other thing that happened was that
the commissioner, in response to a complaint in relation to
a registrar doing a procedure on a patient and consent
(02:37):
for teaching had not been gained for that, and she
made it clear that her view is that consent for
teaching applies not just to medical students but to postgraduate
doctors in training. And so this interpretation has narrowed it
down quite a lot, and I think is given the
context of how few doctors we have and the problem
(02:57):
we have with getting them trained, it's a constraint which
I think is really unhelpful.
Speaker 2 (03:04):
I just don't think, and I don't know because I've
never trained as a doctor. I don't even watch that
many medical shows on television, so I'm not a doctor
in training. But I would have thought that training on dummies,
no matter how lifelike they are, it doesn't prepare you
at all for the real thing.
Speaker 3 (03:24):
No, no, okay, it prepares you. It does prepare you.
And the example in the piece I wrote for the
Conversation was about how you learned to do CPR cardiofomary resuscitation.
And I mean anyone who's done a first aid course
will have seen the dummies that were used to train
people to do CPR, and they're useful. You know. It
means you've got an idea of what it's about. But
(03:45):
one of the things that I have is I get
reflective essays from students, and I've had numerous essays from
students describing their first CPR, where the thing they learned
was how to deal with the fact that you're trying
to help someone's life from you know, to help someone
from dying with relatives around who are acutely distressed, and
(04:06):
about whether you're good enough to do this. Yeah, and
without If you don't do your first CBR, you won't
learn that stuff. But the rules, if they were implemented
by the letter, would mean that no one would ever
learn CBR because you can't get consent from the patient
because they're unconscious of dying.
Speaker 2 (04:28):
Yeah. I remember years ago talking to a doctor, very
senior doctor had done his training at Guys in London
as a young trainee doctor, and they all trooped, about
ten of them trooped in for a woman who was
having a tonsils out. But they were able to give
her an internal examination because the only wombs and the
(04:51):
like that they had had experience on were fallen women.
This was back in the early sixties and they had
no idea what a healthy uterus was like, and because
no decent woman would allow that kind of exploration, they
did it well and more unconscious having other operations, So
we don't want that, do we know well?
Speaker 3 (05:11):
And the history of this is that that was effectively
what was happening in Wellington prior to the Cartwright inquiry.
In fact, my medical student cohort objected to being asked
to do our first vaginal examination on a woman who
wasn't aware that we were doing it because she was
anesthetized in theater. We objected to that. And what I'm
trying to say is that if this is just teaching,
(05:34):
so in that scenario the only thing the student is
doing is learning, they're not involved in the care whatsoever.
Then of course consent is required, you know, and it's
required for all sorts of purposes. But if, for example,
it were a student who was part of the orang
team who were doing a removal of a of a
(05:56):
uterus because of survival cancer, and prior to the procedure,
the student examined that woman to feel what it cat's
felt like. They're part of the team, that part of
the care provision, and I think requiring consent in that
setting it doesn't make any sense because why do we
get consent for the medical student to be there when
we don't get consent for the charge nurse or the
(06:17):
circulator nurse, or the anesthetic teams, all the other people
in theater, we're setting a standard for the medical students
which actually doesn't meet for everyone else's. Look, I understand
the you know, there are some costs here. It's not
it's it's unpleasant and more people doing this than is needed.
I understand that. But as you observe, if if we
(06:39):
don't learn how to examine what a cervix is like
when a baby's coming out, you never know when you're
going to be faced with that as a doctor, and
if you haven't done it before, you're not going to
be able to do a good job.
Speaker 2 (06:49):
And also, yeah, I suppose, but there I suppose there
are different values around bodies. Like I would have no
problem at all, and clearly didn't with trained professionals or
professionals in training using my body while I was making
(07:09):
use of their facilities, you know, making use of their
skills too, And I would still have no problem. Like
if anyone wanted a fossic feel free, you know, go ahead,
But I don't have any cultural hang ups around that.
And I guess that you have to take that into
account too well.
Speaker 3 (07:26):
And the point that I've made is that this is
the consent. Of course, we get consent. I mean, the
thing is that no one is involved in the care
of a patient who's conscious without their consent.
Speaker 1 (07:39):
Yeah.
Speaker 3 (07:39):
You know, either you made an appointment to come and
see me as a GP, or if I suggested you
see the practice nurse, you'll come in and say, oh,
I'm the practice nurse. I've come in to do your
blood sugar. Is that okay? It's part of normal practice
for everything that we get consent for involvement. Yeah, and
I think that we should just say, look, that's normal.
If the patient isn't conscious, you can't get consent for involvement.
(08:01):
And so the protection for patient safety and dignity is
the quality of the supervision. So someone is in control,
the senior clinician. And so in the setting I was
describing in theater where the student might examine a cancer
as cervix, that would be done under the supervision of
the specialist who would make sure that not too many
(08:22):
people did it, and would make sure that it was
done properly and with dignity, and you know, looked after
all of those features and then, of course, the thing
is that we can't consent everything we do because and
because we don't know what's going to happen, and so
during theater you might find an unexpected animality. You wait
the patient up and say, look, would you mind if
(08:43):
I operate on this as well while here. So the
whole model of consent as a way of securing patient
safety and dignity is a poor model for all of
those people who don't have capacity, So all the people
with dementia, all of the children who don't have their
parents present, all of the people in the wards who
are in distress and pain and who have lost capacity.
(09:06):
We don't learn on those with consent because they can't
give us consent.
Speaker 2 (09:10):
So you would you like to have an opt in
facility or an opt out solity?
Speaker 3 (09:17):
Well no, I think my view is that we need
to just reframe this as that. And part of this is,
so what's teaching anyway? And is there a difference between
teaching and learning And is it just students who learn
or teach or is it senior doctors as well? Of
course it's senior doctors as well. That all the surgeons
(09:38):
have learned new procedures since they've been consultant surgeons because
things have changed keyhole surgery for example, now so that
we're learning and teaching all the time. So I think
the idea, firstly that we need explicit consent for it
is it's problematic because of the issues that I've discussed.
So what I think more is that there's always an
(10:01):
opt out, because there's always if you look, if you
don't want me to care for you, then I won't
care for you. You know, this is a basic element
of the Bill of Rights that you can refuse medical treatment.
And that's what it should be with conscious patients, and
then with unconscious patients it should be on the basis
of say, high quality supervision and care and respect and
(10:21):
how you deal with the cultural differences. So, as a GP,
there would be some patients where I might have had
a student with me, and I'd be calling in someone
I thinking, uh, actually, I don't think i'll get the
student with this person because I knew some of the
circumstances of the particular distress or some of their cult values,
and I would, you know, just not call the student.
And so I'm not saying students should be there all
(10:42):
the time. I think the other important point is to
realize that having a student there improves your care. In
that I found as a GP, if the student was
sitting next to me, I was always second guessing, Oh
what would I say to the student? They asked me
why I did that? And they would know more about
the latest drugs and the latest literature because that's what
(11:02):
they've been studying. And so actually having a student as
part of the team means that you get better care overall.
And so I think we need to change the whole
culture in terms of you know, it's great that we've
got students. In fact, what I would like everyone on
your show to do is if they see their GP
in the next few weeks and they don't have a student,
ask them, oh, why don't you have a student? Brilliant?
Speaker 2 (11:26):
Thank you very much. Good to talk. That is doctor
being great, talking about getting more of our teachers, more
of our doctors, the opportunity to learn from doctor teachers
and to learn from the patient teachers.
Speaker 1 (11:41):
For more from Kerry Wood and Mornings, listen live to
news talks. It'd be from nine am weekdays, or follow
the podcast on iHeartRadio.
Popular Podcasts
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.
Bleep! with Ana Navarro
Fear thrives in silence and confusion. Ana Navarro rejects both. Her voice is an antidote to today’s chaos. Her new podcast, Bleep! with Ana Navarro, takes on today’s most pressing issues with the voices most connected to it: decision-makers, political leaders, cultural shapers, and people on the frontlines of the story. The conversations acknowledge the emotions we all feel—despair, sadness, fear— but emerge with knowledge, perspective, and hope. The belief is simple: fearless dialogue can transform fear into courage, and courage into change. When fear dominates the headlines, this show digs deeper. Because information, debate, and conversation don’t just ease fear, they give us power to shape the future.
Hey Jonas!
Hey Jonas! The official Jonas Brothers podcast. Hosted by Kevin, Joe, and Nick Jonas. It’s the Jonas Brothers you know... musicians, actors, and well, yes, brothers. Now, they’re sharing another side of themselves in the playful, intimate, and irreverent way only they can. Spend time with the Jonas Brothers here and stay a little bit longer for deep conversations like never before.