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Competence and Confidentiality: A Guide

Medical ethics is an interview favourite. As an applicant, you may be asked: How would you react if a patient asked you to prescribe a drug they didn’t need? What would you do if you saw a colleague making a mistake with patient notes?

Through such questions, medical schools will try to gauge the way you understand, interpret and react to situations, in an attempt to secure the best potential future generation of doctors.

But why do medical schools put so much emphasis on ethics? Does it mean anything once you’ve passed that interview hurdle?

As a matter of fact, it does. Though it may seem like nothing but an academic exercise when preparing for your interviews, the importance of medical ethics becomes very clear when you become involved in clinical practice. In this blog, I will give you some examples to illustrate this point.

What is Competence?

Needless to say, there’s a lot to learn when training to be a doctor, and no one expects you to gain all of the skills and knowledge that you need overnight. It takes time, practice (and as with anything in medicine, a lot of paperwork) to ensure that students are safe to perform procedures and examinations on real patients. Therefore, the idea of competence is heavily drummed into medical students. You must know your limitations or risk harming a patient.

It seems quite intuitive, and one may question why a medical student would even consider performing something beyond their competence levels. The truth is that, in practice, it is not always so clear cut. We are very used to aligning our moral compasses based on the advice and actions of those senior to us.

But what do we do when those senior to us are more lax about the rules then what we are taught? What do we do when everyone around us expects us to do something that we know we aren’t supposed to?

Can you give an example of a Competence scenario?

Let me put this into context. Imagine you are a bright-eyed, bushy-tailed second-year medical student, starting on your medical rotation, and keen to make a good impression. You are shadowing a senior doctor who is muttering about how inconvenient medical students are, and how they never do anything except get in the way. You see a patient who needs to have their blood taken for testing, but none of the doctors or nurses have time for this right now.

The senior doctor turns to you and says: “finally – a chance to make yourself useful! Do you know how to take blood?” The truth is that you do know how to; you learnt it in the lab, in your first year. But you know you are not supposed to perform this on a patient yet. Everyone on the ward round is watching you. The pressure to accept the task is very high. What do you do?

Competence: What should you do?

This is where medical ethics comes in. Though you are not yet a doctor, you do have a moral responsibility to ensure that patients do not come to harm. Although you may be able to perform this task successfully, there must be a reason behind the fact that you are not supposed to.

Overall, the risk of harm to the patient overrides any potential good you could do by taking the blood without having sufficient training. And even if taking blood seems like an easy and insignificant task, what happens if you are asked in the future to do more difficult and risky procedures?

It is important to recognise your own competence, and to be able to make others around you aware of it. In this situation, therefore, it would be necessary to tell the senior doctor that you cannot perform this task, no matter how difficult it may be.

What is Confidentiality?

Both as a medical student and a doctor, an important aspect of ethics and professionalism is your duty of confidentiality to patients. You must know what confidentiality is, when it applies, and crucially, when it does not.

You will also learn why the duty of confidentiality is so important, and how the doctor-patient relationship hangs in the balance if it is ever compromised. In order to be an effective caregiver, your patient must trust you – and they cannot do so if they do not believe that they can speak to you in confidence.

As with the previous example, this matter seems fairly straightforward and intuitive. Don’t share your patient’s information with other people. Simple, right?

Actually, not so simple. As patients should be aware, doctors are permitted to share details of cases with colleagues involved in the care of the patient, in order to ask for advice and assistance. Furthermore, we are encouraged to use and present cases for educational purposes.

In this situation, however, the cases must be kept entirely anonymous. So, as you can see, it is not a matter of never speaking to anybody about any patients. It is about knowing what you can share with who, and when. This, therefore, takes some getting used to.

Can you give an example of a Confidentiality scenario?

I’ll give you some context. You are a third-year medical student, and have spent the day seeing patients at a local GP surgery. When you come home, you are eager to share the details of some interesting cases with your housemates, who are also medical students.

As you start talking about a young patient with weight loss and possible arthritis, one of your housemates starts questioning you. She is from the local area, and thinks that she recognises the patient who you are talking about. “Is it Jane Doe?!” she asks eagerly. “I had no idea she was having health problems!”

You try to change the subject, but she presses you to confirm the identity of the patient. What do you do?

Confidentiality: What should you do?

It is vital that you remember that your duty of confidentiality does not end when you finish for the day. This scenario is a very common one, and certainly not a situation where the duty does not apply.

The impact on your patient of knowing that the details of her health have been shared without her permission may be destructive of her trust in the healthcare profession, which will impact her future health.

Even if she never finds out, it is morally unacceptable for you to break her confidentiality here. Although it may be difficult for you to say no to your friend, you must be clear that you will not share the patient’s identity.

Having a good grounding in medical ethics allows you to make such decisions unambiguously. In this scenario, your housemate probably needs to revise some medical ethics too…

To conclude:

As you can hopefully now see, the need for strong ethical decision-making runs throughout your medical career, from the minute you start seeing patients. Sometimes the answers are clear, as in the scenarios described above, but sometimes they are not.

Doctors are faced with ethical challenges daily, so developing strong moral frameworks is crucial to being a good doctor, which is why ethics are emphasised at medical school. So, when you try to understand ethical concepts in order to answer interview questions, rest assured that there is good reason behind it.

Words: Mariam Al-Attar

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