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Seeing Is Believing: Balancing the Benefits and Hazards of Medical Observers in the Emergency Department
ETHICS/EDITORIAL
Seeing Is Believing: Balancing the Benefits and Hazards of Medical Observers in the Emergency Department Andrew E. Muck, MD; Robert A. De Lorenzo, MD, MSM* *Corresponding Author. 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.11.033
SEE RELATED ARTICLE, P.
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[Ann Emerg Med. 2016;-:1-3.] People’s minds are changed through observation and not through argument.—Will Rogers1 The scene is familiar: a busy emergency department (ED) with patients, families, physicians, nurses, ambulance crews, light, noise, blood, suffering, and healing. Among this may be a few unfamiliar faces—observers—who seek insight into medical care. As vetted guests of the hospital, the observers witness the mundane and the remarkable, from routine care to resuscitation. They may also have a view of some of the most privileged life moments such as delineating a sexual history or gathering around a dying loved one. In this context, the medical observers are persons not directly participating as members of the care team but viewing and hearing patient care activities to gain general experience or understanding of health care delivery. The practice of ED medical observation2 (or shadowing3) encompasses many different kinds of temporary people, perhaps undergraduate students interested in medicine or individuals from a local organization, who have a desire with positive attributes. Observation is not unique to the ED because observers can be found in all areas of the hospital, outpatient clinics, and the out-of-hospital environment. The ED drama and rapid pace capture the desire of many and make it an appealing location to observe. Limited objective data exist on ED observation, but informal experience suggests that it is widespread. It is likely many physicians participated as observers during their formative education, underscoring one clear positive of this opportunity. Although the overall benefit of such experiences seems intuitive, objective confirmation is lacking. In the accompanying special contribution, Geiderman4 reminds us that medical observation is a balancing act between the benefits accrued to the observer
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(and by extension, society) and the potential hazards to the patient, primarily breach of privacy. Geiderman4 uses the lens of medical ethics to deconstruct the practice of medical observation. In a systematic fashion, he applies the concepts of autonomy, beneficence, nonmaleficence, and honesty to help analyze observerships. Although not specifically identified, respect for persons is implied and woven throughout the substance of the article. In reviewing the sparse literature on the topic, he highlights the relevant court cases and legal considerations supporting the validity of his viewpoint. The article identifies the lack of comprehensive national policies beyond the limited promulgation by the American Medical Association (AMA).5 Reflecting the complexity and novelty of the topic, Geiderman4 intersperses supported statements with opinion. For example, when discussing the ED as a location for observation, he proclaims such patients are “too sick or distressed to give true informed consent..” The hazard in this position is paternalism and loss of patient self-determination; because the topic is not settled and consensus guidelines are lacking, readers must consider the preliminary nature of the discussion before simply accepting this or other conclusions. The article highlights the term “shadowing,” whereby a premedical (college or high school) student observes the physician conducting daily work. While acknowledging the potential societal benefits, Geiderman4 makes the case for a policy requiring consent of each patient observed. Although this policy has merit, the nature of the emergency care makes it challenging to implement. ED or out-of-hospital patient care is not often confined to private rooms and planned encounters. Previous consent in these situations is not possible, and severely restricting or eliminating these observation experiences seems excessive. Instead, we propose that observers seeking a general overview of the ED be restricted to the team workstation area. Common areas
Annals of Emergency Medicine 1
Muck & De Lorenzo
Seeing Is Believing
(nurse stations and team centers) are not patient care areas, and the expectations of privacy are less. We suggest obtaining consent when practicable; if it is not reasonably obtainable (eg, during a resuscitation), the observation could continue because the benefits outweigh the risks. In all cases, compliance with privacy laws (eg, the Health Insurance Portability and Accountability Act) and regulations is a priority. When the privacy of patients in the ED is addressed, it is useful to consider a public good not emphasized by Geiderman4: transparency of care. Preserving the image and mission of emergency medicine through trust and accountability is important in today’s sociopolitical climate. The ED is the site where all are treated fairly, with respect, and in accordance with accepted medical practice. Emergency detention, patient restraint, and rapid tranquilization are just a few of the aggressive yet humane and compassionate actions that occur in a typical ED, but to the untrained eye, they can appear barbaric and even cruel. Highly charged and negative social media accounts, even if spurious, can damage the reputation of the ED as a sanctuary of high-quality medical care. Carefully crafted observerships, with handlers to narrate, can counterbalance negativity by empowering local policymakers and community leaders to reframe the narrative in manner that enhances public perception. Geiderman4 offers his summary recommendations on observers in the medical setting in Table 2 of the article. As a complement to this list, we advocate explicitly introducing the concept of proportionality. The degree of observation (that is, the degree to which a patient’s privacy may be compromised by a stranger’s observation) should be commensurate with the purpose and objective of the observation. Stated differently, we advocate an explicit balance of the goals of an observation with the risk to the patient’s privacy. For example, hospital architects may need to appreciate the overall flow of the ED but have no requirement to observe actual care procedures, whereas outof-hospital personnel observing as part of a continuity-ofcare project may benefit from encounters related to transitions of care. When applying the Geiderman4 recommendations, it is important to avoid overinclusiveness, trapping unintended others in the observer net. By definition, observers are not contributing members of the patient’s medical team. Conversely, students who participate in patient care activities are, by definition, not observers. The role of students and the obligation to balance privacy and the societal need for trained clinicians is established and should not be conflated with medical observation. Students should identify themselves as such, and patients should be notified 2 Annals of Emergency Medicine
ahead of time that students may participate in their care. This often takes the form of a routine notice provided to the patient during the registration process. Students with more indirect roles appear to occupy a gray area between traditional health care students and observers. For example, health care management students observing the flow and timing of patient care or biomedical engineering students observing the interplay of machine and patient share characteristics of both health care students and observers. To limit confusion, the most appropriate approach may be to encompass all students with clear health care–related curricular objectives. This places an appropriate burden of protecting patient privacy on the education program director and faculty. Similarly, observing for performance improvement is likewise not a medical observation in the context of the article by Geiderman.4 Organizations have an obligation to improve their services, and this can be accomplished only through careful validation. Any patient care observed should directly support the performance improvement process, and, when practicable, consent should be obtained. Guidelines and local procedures exist for medical observation and can serve as nidi for more local policies. The AMA and the Association of American Medical Colleges addressed this topic in a narrow context.2,3 Because observerships can both benefit the public and affect patients, we believe professional organizations such as the American College of Emergency Physicians should study this topic and provide guidance and standardization. The ED is a fishbowl through which others look, seeking insight into medical care and careers; we should reasonably control who can observe the care in the ED. Geiderman4 offers a starting point: Carefully crafted and controlled medical observerships can both strengthen public trust and protect patient privacy. After all, seeing is believing. Supervising editor: Donald M. Yealy, MD Author affiliations: From the Department of Emergency Medicine, UT Health San Antonio, San Antonio, TX. Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships Volume
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no.
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:
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2016
Muck & De Lorenzo
Seeing Is Believing
in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
REFERENCES 1. Smallwood JM, Gragert SK. Will Roger’s Daily Telegrams: The Hoover Years, 1931-1933. Claremore, OK: Will Rogers Memorial Museums; 2008. 2. American Medical Association. Establish an observership for international medical graduates. Available at: https://www.ama-assn.
Volume
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no.
-
:
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2016
org/life-career/establish-observership-international-medical-graduates. Accessed November 1, 2016. 3. Association of American Medical Colleges. Guidelines for clinical shadowing experiences for pre-medical students. Available at: https:// www.aamc.org/download/356316/data/shadowingguidelines2013. pdf. Accessed November 1, 2016. 4. Geiderman JM. Observers in the medical setting. Ann Emerg Med. 2016; http://dx.doi.org/10.1016/j.annemergmed.2016.10.006. 5. American Medical Association. Patient privacy and outside observers to the clinical encounter. Available at: http://www.amaassn.org/ama/ pub/physician-resources/medical-ethics/code-medical-ethics/ opinion50591.page? Accessed November 1, 2016.
Annals of Emergency Medicine 3
Seeing Is Believing: Balancing the Benefits and Hazards of Medical Observers in the Emergency Department Andrew E. Muck, MD; Robert A. De Lorenzo, MD, MSM* *Corresponding Author. 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.11.033
SEE RELATED ARTICLE, P.
.
---
[Ann Emerg Med. 2016;-:1-3.] People’s minds are changed through observation and not through argument.—Will Rogers1 The scene is familiar: a busy emergency department (ED) with patients, families, physicians, nurses, ambulance crews, light, noise, blood, suffering, and healing. Among this may be a few unfamiliar faces—observers—who seek insight into medical care. As vetted guests of the hospital, the observers witness the mundane and the remarkable, from routine care to resuscitation. They may also have a view of some of the most privileged life moments such as delineating a sexual history or gathering around a dying loved one. In this context, the medical observers are persons not directly participating as members of the care team but viewing and hearing patient care activities to gain general experience or understanding of health care delivery. The practice of ED medical observation2 (or shadowing3) encompasses many different kinds of temporary people, perhaps undergraduate students interested in medicine or individuals from a local organization, who have a desire with positive attributes. Observation is not unique to the ED because observers can be found in all areas of the hospital, outpatient clinics, and the out-of-hospital environment. The ED drama and rapid pace capture the desire of many and make it an appealing location to observe. Limited objective data exist on ED observation, but informal experience suggests that it is widespread. It is likely many physicians participated as observers during their formative education, underscoring one clear positive of this opportunity. Although the overall benefit of such experiences seems intuitive, objective confirmation is lacking. In the accompanying special contribution, Geiderman4 reminds us that medical observation is a balancing act between the benefits accrued to the observer
Volume
-,
no.
-
:
-
2016
(and by extension, society) and the potential hazards to the patient, primarily breach of privacy. Geiderman4 uses the lens of medical ethics to deconstruct the practice of medical observation. In a systematic fashion, he applies the concepts of autonomy, beneficence, nonmaleficence, and honesty to help analyze observerships. Although not specifically identified, respect for persons is implied and woven throughout the substance of the article. In reviewing the sparse literature on the topic, he highlights the relevant court cases and legal considerations supporting the validity of his viewpoint. The article identifies the lack of comprehensive national policies beyond the limited promulgation by the American Medical Association (AMA).5 Reflecting the complexity and novelty of the topic, Geiderman4 intersperses supported statements with opinion. For example, when discussing the ED as a location for observation, he proclaims such patients are “too sick or distressed to give true informed consent..” The hazard in this position is paternalism and loss of patient self-determination; because the topic is not settled and consensus guidelines are lacking, readers must consider the preliminary nature of the discussion before simply accepting this or other conclusions. The article highlights the term “shadowing,” whereby a premedical (college or high school) student observes the physician conducting daily work. While acknowledging the potential societal benefits, Geiderman4 makes the case for a policy requiring consent of each patient observed. Although this policy has merit, the nature of the emergency care makes it challenging to implement. ED or out-of-hospital patient care is not often confined to private rooms and planned encounters. Previous consent in these situations is not possible, and severely restricting or eliminating these observation experiences seems excessive. Instead, we propose that observers seeking a general overview of the ED be restricted to the team workstation area. Common areas
Annals of Emergency Medicine 1
Muck & De Lorenzo
Seeing Is Believing
(nurse stations and team centers) are not patient care areas, and the expectations of privacy are less. We suggest obtaining consent when practicable; if it is not reasonably obtainable (eg, during a resuscitation), the observation could continue because the benefits outweigh the risks. In all cases, compliance with privacy laws (eg, the Health Insurance Portability and Accountability Act) and regulations is a priority. When the privacy of patients in the ED is addressed, it is useful to consider a public good not emphasized by Geiderman4: transparency of care. Preserving the image and mission of emergency medicine through trust and accountability is important in today’s sociopolitical climate. The ED is the site where all are treated fairly, with respect, and in accordance with accepted medical practice. Emergency detention, patient restraint, and rapid tranquilization are just a few of the aggressive yet humane and compassionate actions that occur in a typical ED, but to the untrained eye, they can appear barbaric and even cruel. Highly charged and negative social media accounts, even if spurious, can damage the reputation of the ED as a sanctuary of high-quality medical care. Carefully crafted observerships, with handlers to narrate, can counterbalance negativity by empowering local policymakers and community leaders to reframe the narrative in manner that enhances public perception. Geiderman4 offers his summary recommendations on observers in the medical setting in Table 2 of the article. As a complement to this list, we advocate explicitly introducing the concept of proportionality. The degree of observation (that is, the degree to which a patient’s privacy may be compromised by a stranger’s observation) should be commensurate with the purpose and objective of the observation. Stated differently, we advocate an explicit balance of the goals of an observation with the risk to the patient’s privacy. For example, hospital architects may need to appreciate the overall flow of the ED but have no requirement to observe actual care procedures, whereas outof-hospital personnel observing as part of a continuity-ofcare project may benefit from encounters related to transitions of care. When applying the Geiderman4 recommendations, it is important to avoid overinclusiveness, trapping unintended others in the observer net. By definition, observers are not contributing members of the patient’s medical team. Conversely, students who participate in patient care activities are, by definition, not observers. The role of students and the obligation to balance privacy and the societal need for trained clinicians is established and should not be conflated with medical observation. Students should identify themselves as such, and patients should be notified 2 Annals of Emergency Medicine
ahead of time that students may participate in their care. This often takes the form of a routine notice provided to the patient during the registration process. Students with more indirect roles appear to occupy a gray area between traditional health care students and observers. For example, health care management students observing the flow and timing of patient care or biomedical engineering students observing the interplay of machine and patient share characteristics of both health care students and observers. To limit confusion, the most appropriate approach may be to encompass all students with clear health care–related curricular objectives. This places an appropriate burden of protecting patient privacy on the education program director and faculty. Similarly, observing for performance improvement is likewise not a medical observation in the context of the article by Geiderman.4 Organizations have an obligation to improve their services, and this can be accomplished only through careful validation. Any patient care observed should directly support the performance improvement process, and, when practicable, consent should be obtained. Guidelines and local procedures exist for medical observation and can serve as nidi for more local policies. The AMA and the Association of American Medical Colleges addressed this topic in a narrow context.2,3 Because observerships can both benefit the public and affect patients, we believe professional organizations such as the American College of Emergency Physicians should study this topic and provide guidance and standardization. The ED is a fishbowl through which others look, seeking insight into medical care and careers; we should reasonably control who can observe the care in the ED. Geiderman4 offers a starting point: Carefully crafted and controlled medical observerships can both strengthen public trust and protect patient privacy. After all, seeing is believing. Supervising editor: Donald M. Yealy, MD Author affiliations: From the Department of Emergency Medicine, UT Health San Antonio, San Antonio, TX. Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships Volume
-,
no.
-
:
-
2016
Muck & De Lorenzo
Seeing Is Believing
in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
REFERENCES 1. Smallwood JM, Gragert SK. Will Roger’s Daily Telegrams: The Hoover Years, 1931-1933. Claremore, OK: Will Rogers Memorial Museums; 2008. 2. American Medical Association. Establish an observership for international medical graduates. Available at: https://www.ama-assn.
Volume
-,
no.
-
:
-
2016
org/life-career/establish-observership-international-medical-graduates. Accessed November 1, 2016. 3. Association of American Medical Colleges. Guidelines for clinical shadowing experiences for pre-medical students. Available at: https:// www.aamc.org/download/356316/data/shadowingguidelines2013. pdf. Accessed November 1, 2016. 4. Geiderman JM. Observers in the medical setting. Ann Emerg Med. 2016; http://dx.doi.org/10.1016/j.annemergmed.2016.10.006. 5. American Medical Association. Patient privacy and outside observers to the clinical encounter. Available at: http://www.amaassn.org/ama/ pub/physician-resources/medical-ethics/code-medical-ethics/ opinion50591.page? Accessed November 1, 2016.
Annals of Emergency Medicine 3