Use of patients in professional medical examinations: current UK practice and the ethicolegal implications for medical education

Involvement of real patients in undergraduate examinations

“Patient” groups and models used—Nineteen of the 20 responding schools had clinical students and all 19 used real patients in the assessment of undergraduates (the odd one out is St Andrew's, which at present has only preclinical students). In addition, actors were used by 15 schools, volunteers by 14, manikins by all 19, videos by 11, and simulators by four. Patients are involved in objective structured clinical examinations (OSCE) in 15 schools, for “long cases” in 13, and for “short cases” in eight. Each of these formats is likely to include physical examination of the patient. Large numbers of patients participate: 12 schools reported using more than 100 patients a year, and seven reported using between 40 and 100 patients.

Recruitment

Who is responsible for recruiting the patients?—In 18 schools doctors were responsible for recruiting patients, and they were likely to obtain them from other clinicians' lists as well as their own. Five schools involved administrators in this task. No school volunteered information on whether non-clinical staff receive training or supervision before contacting patients, and this point remains unclear.

From what source(s) are patients initially recruited for participation in exams?—All schools recruited patients from outpatient lists; 14 schools asked general practitioners; and 16 made use of their current inpatients.

What payment, if any, do patients receive for their involvement in professional examinations?—Sixteen hospitals reimbursed only patients' expenses; six offered a flat rate fee or honorarium; five provided a gift; and two gave nothing. Arrangements may differ within a school depending on the examination concerned.

Preparatory information given to patients—Eighteen schools informed patients about practical matters such as travel arrangements and expenses. All the 19 clinical schools gave dates, times, and the location of the examination, and 16 acquainted patients with its purpose. Nine schools reported that some form of consent was obtained before the examination. Only three described the clinical care available to patients during their part in the examination.

How is this information delivered to patients and by whom?—Seventeen schools contacted patients by post, nine used the telephone, and nine arranged a meeting. In 11 schools clerical or administrative staff made this contact; in 18, doctors were involved.

Information about patients

In general, to what extent do you know the medical details of participating patients?—Depending on the examination setting, nine schools had access to patients' full medical records; 10 had a short précis of history, examination, and investigations; seven had only a statement of diagnosis.

How is patient information stored for use in subsequent exams?—Twelve schools store patient information on paper, 11 in computer files; two schools used other methods, and three did not store patients' data.

Clinical care for patients on the day of the student assessments

Where do the examinations involving patients take place?—Hospital wards were used in 13 schools, outpatient departments in 11, and “other clinical areas” in 10. It was unclear if these clinical areas are designated for educational use only, in which case the facilities for emergency patient care would probably be reduced or non-existent. Eleven schools used “educational spaces” which they all termed a “skills laboratory.”

In general, who (excluding examiners) is directly responsible for supervising the patients?—In 13 schools a named person was responsible for providing clinical care for patients. Nurses were involved in clinical supervision at 17 schools, though no school reported that nurses were involved in the recruiting or preparatory communication with patients; doctors were involved in clinical supervision in 17 schools. In 11 schools administrators had responsibility for supervising the patients.

In general, what facilities do you have available for the patients on the day of the examination?—Provision varied from school to school. All 19 provided a bed or couch; a resuscitation team was available in 17 cases, a resuscitation trolley in 16, oxygen in 14, a basic first aid kit in 13, a selection of drugs in 13, an electrocardiograph in 12, and a glucometer in 11; nine schools had an ambulance service standing by, and three schools claimed to make “other provisions.”

Drugs available and who would administer them—At six schools (30%) over the counter drugs were available and at eight (40%) prescription only drugs. The range of available drugs included simple analgesia in 11 cases, inhalers and nebulisers in eight, intravenous frusemide in eight, opiate analgesia in seven, and “other drugs” in four cases, regardless of the examination setting. Eight schools stated that a doctor was described as responsible for giving these drugs. However two schools stated that an administrator would give drug treatment.

Adverse events—All the 19 clinical schools had experience of an adverse event involving a patient during undergraduate assessments. In 10 schools a patient's existing clinical condition had deteriorated during the course of an exam; in two a previously undiagnosed condition had been discovered; and three schools had experience of a patient dying in the course of an exam. Two schools reported onset of labour and two reported accidents or injuries to a patient. Eleven schools said that a named person was responsible for responding to adverse events involving patients and 14 felt their response to the adverse events they described was adequate.

Opportunist second opinions—Patients sometimes seek advice from clinicians who are not directly responsible for their care: five schools (25%) reported this occurring.

Consent

Valid consent, given by a competent person, is informed, voluntary, and continuing. Most schools limit to practicalities the information they give to patients about the examination in which they are to take part, although almost half of schools believe that they are thereby seeking consent from patients. Adults are presumed to be competent,11 but where there is doubt an assessment based on established criteria should be made.12 Patients should be given information covering the points in the box.

Eighteen of the 19 schools involve doctors in recruiting patients for examinations. Patients and doctors are not in an equal relationship, and evidence shows that patients seek to please their doctors.13 Patients should be reassured that refusing to participate in student assessments will not compromise their care. Payment can further complicate the issue of consent. By analogy with consent for participation in research,14 if payment exceeds what can be considered reasonable recompense for the expenses and inconvenience of participation, it may constitute an inducement and invalidate consent. Our study found that is usual for expenses to be reimbursed; sometimes a flat fee or honorarium is paid; five schools give patients a gift for attending.

Confidentiality and data protection

Most medical schools store data about the patients used in undergraduate examinations, which raises questions about confidentiality and data protection. It is common for both clinical and non-clinical staff to have access to patient information. Indeed, in more than half the schools a patient's complete medical record is made available—more than is generally required for organising an assessment of students. Medical schools should be aware of their responsibilities following the Caldicott recommendations on protecting patient data, and under the Data Protection Act 1998. 15 16 Schools also have a responsibility to train staff about the importance of confidentiality.

Duties and standards of care

The extent of the duties of care of parties involved in assessment of students is complex. In 11 of the 20 of schools, these examinations take place in an educational setting. Have the organisers or the examiners (or both) undertaken a legal duty of care for the participating patients? Some commentators have argued that staff have a legal duty of care to act in emergencies that occur in or near a clinical location.17 This argument has been accepted in an Australian case.18

The General Medical Council is clear that all doctors have an ethical duty to provide treatment that could reasonably be expected to be provided in emergencies.19 However, our study found the equipment and staff required to manage common medical emergencies are not always available at sites of student assessments. We found that emergency facilities ranged widely from the provision of simple analgesia to that of intravenously administered drugs and full resuscitation facilities. Should it be the responsibility of the organisers to ensure that there is someone on site for the duration of each student examination who is trained in operating the emergency equipment and administering the treatment that is available?

Questions of duties of care also arise in routine exchanges between patients and doctors on these occasions. About half of respondents reported that patients acting as clinical “cases” had during this contact with doctors either received or solicited medical advice. How should examiners respond to such requests?

Adverse and unexpected events

We found that all 19 clinical schools had experienced what might be described as an adverse event during student clinical assessments. Organisers need procedures not only to be able to manage adverse events but also to ensure that the details are afterwards communicated to the patient's healthcare team. It should be clear who is to take responsibility for leading the inquiry procedure into adverse events and for liaison with the patient's regular health carers.

Conclusion

The results of this survey indicate that there is a wide variation in the experiences of using real patients in undergraduate examinations at UK medical schools. Important ethical and legal issues arise at all stages of organising an assessment in which patients are to be involved. The value of using real patients is well documented.3^–6 However, patients must be more than merely means to desirable educational ends. Anyone involved in medical education has duties and responsibilities to those patients who volunteer to help in the training of doctors.

The findings of this study are applicable to patients participating in medical education at all stages of training—undergraduate, postgraduate, and continuing medical education. All medical schools that involve patients in medical education should consider drawing up local guidelines that cover the key ethical and legal issues listed in the box.