Document Type: Letter to Editor


Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran


Dear editor Clinical environments encounter is an important part of studying medicine (1). Patient contact as an integral part of medical education occurs in various formats in the clinical settings (2, 3). During clinical training, medical students may experience high levels of stress, and some may not deal with it well. The abruptness of students’ transition to the clinical setting generated positive and negative emotions. Due to being a novice, they did not receive adequate training on how to get emotionally prepared for meeting seriously ill people. In such circumstances, the shortage of training will have predictably crucial consequences. Early clinical contact has been suggested to reduce these stresses and help the students adapt effectively to changes in the hospital climate (2). Patient contact creates an environment where each student appreciates cultural diversity and reinforces the development of clinical professional interpersonal skills through social, emotional and cognitive experiences (4, 5). It encourages validating of the relationship between patients and doctors and allows students to experience a more personal relationship with patients and nurture the ability to empathize with them, providing considerable benefits for trainees and patients. In this way, the social emotions that students experience when empathizing with a patient represent a uniquely human achievement. By internalizing their  subjective interpretations of patient’s beliefs and feelings, the student’s body, brain and mind come together to produce cognition and emotion . They construct culturally relevant knowledge and make decisions about how to act and think about the patient’s problems as if they were their own. On the other hand, patient interaction in undergraduate education offers students a valuable early insight into the day-to-day role of a doctor and the patients’ perspective on specific conditions. Early experience provides a greater knowledge of professional roles and responsibilities for students (6- 8). Considering the important role of patients in contributing to the educational process and the benefits that exposure to patients will have for the students, it is important to note that medical schools bear the responsibility of training their students in a framework to approach these experiences in a professional way. It is necessary that medical training programs begin to provide adequate and formalised preparation for ethical challenges of working in clinical settings. While a large bulk of feedback from patients showed generally positive attitude toward medical student participation, there may still be the risk of adverse effect on the clinical teaching environment. Thus, patients should be adequately informed and permission should be obtained for medical students’ involvement. Previous studies have indicated that medical students often face ethical dilemmas concerning patient-care.  A study conducted by Walters et al. (2003) reported some therapeutic benefits, for patients with common mental disorders contributing in undergraduate teaching in general practice .The study revealed that there were high levels of patient satisfaction; however, a small number of patients reported that they found the encounter distressing (9). Teaching hospitals need to become a safe and sacred place of respect for human rights and dignity (10). There are numerous ethical dilemmas to the patient involvement in medical education that may have unintended consequences such as loss of privacy and missing the patient’s emotional and personal responses. An ethically sensitive organization often faces the probe of having to balance between duty of training the students well and duty of doing the best care for the patients. The main point of this ethical dilemma is beneficence to the students versus non- malfeasance (harm) to patients. Ethical sensitivity can be promoted by development of ethical guidelines proposed for patient-oriented teaching hospitals.The common ethical principles that guide all medical practices are central to any contact with patients at all stages of medical education. Patients may express concerns over their involvement in medical education as well as over breaching ethical considerations including consent and confidentiality. Lack of related concerns could have a negative impact on patients and on the learning outcomes for medical students, trainees and doctors (11). With increased focus on patients’ autonomy, this principle is also ignored when no freedom of choice is given to the patients being visited by the trainees. Therefore, it is essential to respect the patient’s right to be informed about any teaching activity in which he or she will contribute, and specific consent must be obtained for student contact (12). Patients must be given the authority of choosing whether students observe or participate during their visit and also should be reassured that doing so will not affect the care they receive. The experiences of patients who participate in medical education will be particularly dependent on the level of information that they receive and thus the extent of knowledge they have about the teaching situation to which they are being asked to consent (12). If the treating team has a good rapport with the patient and if the patient is assured that he or she  will not be harmed or embarrassed  in the proposed activity, most of them would cooperate and contribute to the education and training of medical students willingly (13). Patients should be informed that necessary information will be shared with students as a part of the learning process and the students have a duty to maintain the confidentiality of the information (1).                                                            In conclusion, clinical exposure in the undergraduate program provides opportunities for medical students to develop professional behavior. They must communicate well and respect their patients’ wishes and needs as expected as to be doctors. For promoting medical education, sufficient weight should be given to the ethical, professional, attitudinal, and social features of medical practice. Therefore, treatment of affective and social learning in modern medical education must be considered as well as scientific foundations of medicine.