Teaching and learning in general practice: ethical and legal considerations for GP teachers and medical students

Differences between general practice and hospital settings have ethical and legal implications for teachers and learners

The general practice setting provides a learning environment that creates a unique ethical and legal milieu for the general practitioner, the patient and the student. It is a less formal, more intimate and less anonymous setting than the hospital environment, and GPs often have long‐established relationships with patients and detailed knowledge of their circumstances. As a community‐centred enterprise, social connections between patients, their families, practice staff and the GP, and sometimes also students, may foster unintended breaches of confidentiality and a vulnerability to boundary crossings.1

The small business environment of general practice exposes students to a lean, fast‐paced clinical environment. One‐on‐one teaching, relatively informal hierarchies and the relative isolation of both GPs and students from their peers are characteristic of the teaching setting. The undifferentiated, across the lifespan clinical environment creates unpredictability about patient presentations and the potential for a broad range of ethical issues to surface. All these factors have implications for patients, students and GP teachers.

Patient‐centred teaching

Patients report several benefits from medical student involvement in their general practice consultations, including enhanced knowledge about their medical conditions and a sense of altruism from contributing to medical education.2 However, some patients have reported concealing information, avoiding raising personal matters and/or omitting to mention what they had intended to discuss with their GP when a student is present.3 Some patients have reported experiencing less relational empathy from their GP due to the student presence.2 Many patients prefer to interact and establish relationships with students, rather than seeing students as passive observers (Box 1).4,5,6 Patient attitudes to student teaching during telephone and/or video consultations have not been explored.

Patient consent

Although teaching medical students is often considered a professional duty, patients have no such obligation.5 Despite the fast‐paced clinical environment of general practice, patient consent for student involvement requires careful attention, including in telehealth consultations. It may be difficult for patients to refuse consent, and some may regret having provided it.3 Both student sex and any prior acquaintance with students may influence their willingness to consent.7,8 Some patients prefer not to have students undertake any part of a consultation without the GP being present.9

It is recommended that patients be adequately forewarned of the student's potential involvement, rather than consent being sought on entry to the consulting room.10 Patients report being uncertain about student qualifications and their role,4 and both students and teachers have been reported to misrepresent the student's status.11 Students should be introduced to patients as students rather than junior doctors, colleagues, or doctors in training.11 If students seek patient consent for their involvement in the consultation themselves, it provides patients with an opportunity to ask questions and make a more informed choice.12

Given the unpredictability of general practice consultations, consent is better understood as a process rather than a single event. Consistent with legal requirements, patients express a desire for an iterative consent to student involvement if the consultation evolves into other areas.4 If, for example, a consultation moves into more sensitive areas, it is appropriate to remind patients that they may withdraw their consent to student participation, and ask the student to leave.

It is the responsibility of the GP teacher to ensure that informed consent is obtained for procedures undertaken by students.11 This includes advising patients of risks, benefits and alternatives. In disclosure of risk, it may be appropriate to include the student's experience of undertaking a task or procedure.11 As students may adopt strategies to appear as competent as possible and avoid revealing areas of deficiency,13 careful assessment of a student's capabilities is recommended before entrusting a task to a student.

The presence of the student should be documented in the consultation record. Verbal patient consent is usually adequate, but this should always be documented. In telehealth consultations, there should be clarity about who is participating, their roles, and reassurance that the consultation is not being recorded. It is recommended that GP teachers adopt a risk‐based approach and consider obtaining written consent in situations where there may be greater sensitivity or risk (Box 2).

Student–patient boundaries

Due to the relative intimacy of general practice consultations, teachers should remind students to be vigilant about boundary crossings and patient perceptions thereof, including when students commence patient consultations independently.6 Students may also be vulnerable to professional boundary crossings with patients in the community and should be encouraged to raise any concerns or discomfort about patients with their teacher.

Patients may reveal information to the student but ask them not to divulge this to the GP. It has been recommended to inform patients, as part of the consent process, that students are expected to share information with their GP teacher.11 Students should be advised to defer back to their teacher if patients ask them to clarify or expand on the information provided by the GP.11

Confidentiality

Long term therapeutic relationships with patients and families in general practice increase the likelihood that consultations and medical records will include sensitive information. Students should be advised to take great care not to breach patient confidentiality inadvertently, including when chatting to practice staff, who are often members of the community which the practice serves. Students in rural settings may encounter patients in local supermarkets and other contexts where confidentiality must be carefully observed. Students should not discuss patient concerns outside the practice, even if patients initiate the discussion. The privacy and security surrounding telehealth consultations is an emerging issue that also needs careful consideration.

General practice patients prefer to be reassured of the student's duty to respect confidentiality and receive confirmation from the student that what has been discussed is confidential.4 It is recommended that medical students sign and abide by a standard confidentiality agreement and practice privacy policy as signed by other practice staff (Box 2).

It is important to advise patients when students will have access to medical records for training purposes. Confidentiality extends to information in medical records, including pathology results and correspondence. The need to respect the patient's physical autonomy and the informational autonomy has been described.11 Patients may expect students to have limited or no access to their records and for their GPs to withhold sensitive information from students.14

Impaired students

Similar to fully qualified health professionals, students are regulated and can have conditions placed on their registration.11 The opportunity for close, one‐on‐one monitoring in general practice placements may allow GPs to detect or confirm suspicions of a student's impairment (such as substance misuse) that may pose a substantial risk of harm to the public while the student is undertaking clinical training. GPs with these concerns should advise the medical school and consider seeking advice from their medical defence organisation and state Doctor's Health Advisory Service or equivalent regarding whether the GP should notify the Australian Health Practitioner Regulation Agency (AHPRA) under mandatory notification requirements and for resources to support the student. Medical schools are required to inform GP teachers of relevant conditions concerning student registration and notify AHPRA if a student has a notifiable impairment.

The mentoring role

Students on general practice placements are often relatively isolated from their peers. They may feel exposed and hesitate to disclose personal emotional or psychological issues. Within the fast‐paced clinical environment, it is important that GP teachers create opportunities to debrief after disturbing, unpleasant or challenging encounters with patients. Students may also be the recipients of unpleasant comments or behaviour of a racial, ethnic or sexist nature from patients. Strong support from their teacher may mitigate any negative impact (Box 3).

The broad spectrum of patient presentations in general practice may increase the probability that students identify with patients’ symptoms or medical conditions. Although mentoring students is an important role of GP teachers,10 it is recommended that teachers do not take on the role of the student's own GP. Students should also not be placed in a medical practice where they are already a patient.11 Box 3 includes suggestions for managing the mentoring role without risking student–teacher boundary crossings.

Teaching about ethical issues

The one‐on‐one, clinically diverse teaching environment is also conducive to unpacking the broad range of ethical scenarios inherent in everyday general practice and modelling the fundamentally ethical enterprise of the medical profession.15 The small business environment exposes students to issues of health care funding, remuneration and affordability at a more personal level than the hospital environment. Clinical and ethical uncertainty may be more prevalent in general practice and may be unsettling to students. Students may avoid discussing their disquieting concerns over aspects of patient management or even perceived lapses in professionalism unless actively encouraged to do so.16 These may arise in grey areas where best practice is not necessarily clear or may be due to background information about the patient which is known to the GP but not to the student. Addressing student concerns may result in meaningful conversations that are useful for both the student and the teacher and may assist students in developing their ethical reasoning.15,16

Conclusion

The general practice teaching context differs from the hospital context and presents its own ethical and legal considerations for GP teachers. Being mindful of these considerations will help ensure positive and patient‐centred teaching and learning in general practice placements.