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The junior doctor as ethically unique
  1. R McDougall
  1. Ms R McDougall, Centre for Health and Society, Level 4, 207 Bouverie St, University of Melbourne, VIC 3010, Australia; r.mcdougall{at}pgrad.unimelb.edu.au

Abstract

This paper argues that the professional situation of junior doctors is unique in ethically important ways and thus that ethics work focusing on junior doctors specifically is necessary. Unlike the medical student or the more senior doctor, the doctor in his or her early postgraduate years is simultaneously a responsible health professional, a subjugate learner and a human resource. These multiple roles generate the set of ethical issues faced by junior doctors, a set that has some overlaps with that faced by medical students and with that faced by more experienced doctors but is far from completely continuous with either. Further, the multiple roles that junior doctors play affect their options for negotiating the ethical challenges that they face. Their position determines not only the content of the set of ethical issues that they encounter, but also the kinds of actions they can take in the face of these challenges. Thus considering junior doctors only in combination with medical students or more senior doctors fails on two fronts. Firstly, only a very incomplete set of the ethical issues faced by junior doctors will be addressed, and, secondly, the constraints associated with the specific professional situation of junior doctors will not be adequately considered, limiting the practical applicability for these agents of any such analyses.

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Medical ethics resources available to doctors tend to address the profession as a whole, rather than making distinctions between junior doctors and their more senior colleagues.1 2 Ethics writing that does focus on doctors in their early postgraduate years usually considers this group in combination with medical students, conceptualising issues as those faced by medical “trainees”.3 4 In this paper I suggest that junior doctors ought to be the subject of specific ethical consideration, arguing for recognition of the ethically unique features of their situation alongside its continuities with that of medical students and more experienced doctors.

The paper is in three sections. In the first, I argue that junior doctors are positioned by their organisational setting such that they play (at least) three different roles simultaneously: responsible clinician, subjugate learner and human resource. In the second section, I argue that this multiple-role position generates a unique set of ethical issues for junior doctors, one that is made up of issues associated with each of their various roles and also with the occupation of multiple roles. In the third section, I claim that junior doctors’ multiple-role position also determines the kinds of actions junior doctors can take in the face of these ethical challenges, and thus that normative work must recognise their particular situation in order to be of practical usefulness to this group.

By junior doctors, I mean those doctors in their first few years after graduation, who occupy the most junior rank in the hierarchically structured medical team. My focus is on the Australian context, so I will use the Australian terminology of “interns” (for graduates in their first year after graduation) and “residents” (for those in their second or third postgraduate year). I will also base my discussion of junior doctors’ organisational context on the situation in the Australian state of Victoria. However, most of the features discussed are substantially similar in many other places. It is also worth highlighting that I use a broad understanding of the concept of “ethical issues” in this paper, looking beyond the standard medical ethics fare of dramatic technology-driven dilemmas and the doctor–patient relationship to include also everyday ethical challenges and those arising in doctors’ relationships with people other than patients, particularly colleagues.5 6 I draw on Holm’s deliberately inclusive definition of ethical considerations; he writes “a consideration is …classified as an ethical consideration if it: a) refers to a non-legal or not solely legal norm, duty, obligation or right; or b) refers to consequences (well-being, happiness etc.) for some specifiable person or groups of persons; or c) refers to what kind of person one ought to be or what virtues one ought to have.”7 On the basis of particularly the second part of this definition, any aspect of the professional situation of junior doctors that creates suffering for patients or for junior doctors themselves involves ethical considerations, and thus can be framed as an ethical issue.

PLAYING MULTIPLE ROLES

The role of medical students in the hospital context is unambiguous, at least from the organisation’s perspective: medical students are learners, spending time in the hospital in order to prepare for their future professional responsibilities. Junior doctors’ role within the organisation, however, is far more complex. In contrast with their time spent on wards as medical students, junior doctors have significant patient care responsibilities: admitting patients, prescribing drugs, maintaining medical records, etc. In this sense, junior doctors’ organisational context positions them as responsible clinicians. However, other features of junior doctors’ working context emphasise that they remain students, with a body of knowledge and skills still to be learnt. For example, junior doctors work in the context of strictly hierarchical teams in which they overtly occupy the most junior rank, taught and supervised by the doctors occupying the variously more senior ranks. Interns are granted only provisional medical registration to enable them to undertake their internship year, and junior doctors’ early postgraduate years are regulated by bodies that accredit internship (and in some cases residency) positions partly in terms of the educational value of the job’s content. The work of Yedidia and colleagues8 highlights that junior doctors in some contexts also play the role of teacher, supervising medical students or interns.

Further aspects of the organisational setting position junior doctors as human resources. The obligations involved in the internship job match are a particularly clear example of this. In Victoria, each yearly cohort of applicants is allocated to internships via a computer matching process that aims to maximally fulfil both the candidates’ and the hospitals’ preferences. Hospitals and candidates must agree to abide by the outcome of the match on threat of exclusion from future matches; hospitals are obliged to appoint, and candidates to accept, the positions as generated by the matching process.9 Structuring the job application process in this way positions junior doctors as a resource to be distributed for the maximal benefit of the patient community. Junior doctors’ lack of control over their particular rotations in a job and the long and often antisocial hours they are required to work provide further evidence for their role as human resources. Thus, unlike the medical student whose organisational role is clearly that of learner, the junior doctor is positioned in (at least) three roles simultaneously by their working context: responsible clinician, subjugate learner and human resource.

A UNIQUE SET OF ISSUES

Occupying these multiple roles creates for interns and residents a specific set of ethical issues that differs from that faced by medical students or more senior doctors. Being both subjugate learners and responsible clinicians, junior doctors encounter a combination of the challenges of the medical student and the more senior doctor, as well as additional issues generated by their role as human resource. For example, empirical studies indicate that junior doctors face ethical challenges around telling the truth to patients about diagnoses and prognoses, and around maintaining confidentiality.1013 These types of ethical issue are obviously also encountered by doctors at more senior professional stages. Results of empirical studies of junior doctors also point to significant commonalities with the ethical issues faced by medical students.14 Issues such as revealing inexperience, harming patients through involving them in medical education, and subjugating their own values to those of their superiors are experienced by both groups.4 10 11 15

The additional ethical challenges relating to the role of human resource tend to be unique to junior doctors. One such ethical challenge is dealing with the transience created by the constant rotations. Christakis and Feudtner16 suggest that this transience necessarily affects the nature of junior doctors’ relationships with patients and with their fellow hospital workers. They argue that junior doctors’ constant movement through different units encourages the avoidance of intimate or committed doctor–patient interactions, and contributes to the erosion of junior doctors’ empathy. In terms of colleague relationships, Christakis and Feudtner suggest that transient placements result in workers merely fulfilling role expectations and, unreflectively, deferring to authority. They also mention the effects on junior doctors’ personal lives, referring to the “social isolation” that the rotation system creates. Dimsdale’s qualitative work with interns supports this contention; participants in his study “complained of limited friendships and social ties” resulting from their geographical transience.17 Similarly, Mumford18 notes the negative impact of transience on interns’ ability to form ongoing supportive friendships with their peers.

Junior doctors thus face ethical issues arising from each of the individual roles that they play. They also face ethical challenges resulting from tensions between their multiple roles. Hoop19 has argued, in the context of psychiatric residents specifically, that ethical challenges arise for this group as a result of the conflicting duties associated with being a physician, a learner, a supervisee and an employee. He cites examples such as “a resident performing a lumbar puncture for the first time, knowing that he is likely to cause the patient unnecessary discomfort and that more skilful hands are readily available”; this is presented as a conflict between the physician’s duty to consider patients as ends in themselves and the learner’s duty to become adequately trained for the benefit of future patients (p 184). Although the issues need not necessarily be conceptualised as conflicts of duties specifically, Hoop’s fundamental point applies to junior doctors beyond just the psychiatric context; a variety of the ethical challenges faced by junior doctors arise as a result of their position playing multiple roles simultaneously. For example, the challenge of maintaining compassion for patients in the face of fatigue, stress and transience is one that has been widely discussed (see Hundert et al3 (p 624), Kushner and Thomasma4 (pp 104–12), Christakis and Feudtner16 and Biaggi et al20). This challenge could be understood as generated by the conflicting demands of being a human resource (expected to contribute long hours and work transiently wherever required) and a responsible clinician committed to delivering optimal patient care. Negotiating a lack of supervision and dealing with mistakes could similarly be seen as ethical issues created by junior doctors’ multiple roles; these challenges result from junior doctors being both responsible clinicians and subjugate learners.

Although I have not attempted to specify all of the ethical issues that face junior doctors, the issues I have highlighted together indicate that ethicists ought not to consider junior doctors only in combination with medical students or more senior doctors if they aim to capture junior doctors’ ethical issues comprehensively. As a result of their occupying the multiple roles outlined, junior doctors face a set of ethical issues that is clearly specific to this group and only partially overlapping with the set faced by medical students and the set faced by more senior doctors. In the next section, I will argue that junior doctors’ multiple-role position also determines their possibilities for action in the face of their unique set of ethical challenges and thus that it ought to play a prominent role in normative analyses of these issues.

LIMITED ACTION OPTIONS

Hospitals are highly hierarchical working environments. As various social scientists, such as Chambliss,21 have noted, the actions available to an agent in the hospital context are limited by his or her role in the system. For example, the ethnographer, Bosk, observes that “[t]he subordinate [doctor] is compelled for all practical purposes to accept…[the consultant’s] definition of reality, however much he may resent it, distrust it, or disagree with it”.22 Kushner and Thomasma4 similarly write of the “frankly limited agency” for subordinates that the hierarchical nature of medicine creates (p 127). Sinclair,23 in his ethnography of medical training in the UK, is specific in highlighting the way in which junior doctors’ working environment and career trajectory structures place genuine limitations on the possible actions an agent in this position can perform:

housemen [interns], because of their short appointments and their dependence on their consultant for a reference for their next job, and their difficulty in co-operative organisation, are in no position to change the system they find themselves in.

Normative analysis of junior doctors’ ethical issues needs to take their particular position into account, as being situated in this way has significant implications for the action options available to these agents. For example, when faced with the ethical challenge of maintaining compassion for patients in the face of fatigue, stress and transience, various possibilities for dealing with this issue are simply not available to junior doctors. The context in which the ethical issue arises is, to a very substantial degree, fixed beyond their control. They cannot choose to avoid rotating or to work fewer hours, or have any significant impact on the pressure levels in their working environment. Their junior role in the hierarchy and the imposed structure of their professional lives limit the kinds of actions they can take in this, as in many, ethically charged situations. Being a junior doctor specifically both limits to a particular range the actual options available to an agent and also determines the personal costs associated with the various available options, in terms of creating disharmony within the team, offending assessors or alienating peers.

Accepting this claim that junior doctors’ particular professional situation limits their action options implies that normative analysis of junior doctors’ ethical issues needs to take their specific position into account. It suggests that the usefulness of ethical work that considers junior doctors only in combination with medical students or more senior doctors will be limited; where the discussion of what ought to be done does not engage with junior doctors’ organisational situation and the multiple-role position that they occupy within it, it can only be of limited usefulness to this group.

CONCLUSION

I have argued that junior doctors occupy a unique position in their organisational setting and thus that ethical consideration of this group specifically is necessary. Considering junior doctors only in combination with medical students or more senior doctors fails to capture the entire set of ethical issues associated with interns and residents, as junior doctors uniquely function as responsible clinicians, subjugate learners and human resources. Playing these multiple roles both generates a particular set of ethical issues and determines in significant ways the action options available to junior doctors facing these challenges. Therefore, although there are some important ethically relevant commonalities between junior doctors and medical students and between junior and senior doctors that justify combined consideration in relation to some issues, it is crucial that the totality of normative work on junior doctors’ ethical issues includes analysis that focuses specifically on interns and residents.

Acknowledgments

I would like to thank Adam Cureton and the two Journal of Medical Ethics reviewers for their helpful comments on earlier drafts of this paper.

REFERENCES

Footnotes

  • Funding: This work was funded by an Australian Postgraduate Award.

  • Competing interests: None declared.

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