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Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.
The Ethical Dilemma of Treating an Attending
Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.
This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?
Ethics Curriculum for Residents
Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.1
One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.2 These themes must be considered in different permutations throughout ethical conundrums.
In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al3 shows. The patient’s autonomy allows them to choose their treating provider.
However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.4 Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.
The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.
Navigating the Ethics of Treating Family Members
The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.10
The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.10 If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.
Treating Nonsupervisory Attendings
In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.
Final Thoughts
Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.
Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.
- Dermatoethics. American Board of Dermatology website. Accessed August 9, 2022. https://www.abderm.org/residents-and-fellows/dermatoethics
- House JB, Theyyunni N, Barnosky AR, et al. Understanding ethical dilemmas in the emergency department: views from medical students’ essays. J Emerg Med. 2015;48:492-498.
- Unruh KP, Dhulipala SC, Holt GE. Patient understanding of the role of the orthopedic resident. J Surg Educ. 2013;70:345-349.
- Grandhi R, Grant-Kels JM. Naked and vulnerable: the ethics of chaperoning full-body skin examinations. J Am Acad Dermatol. 2017;76:1221-1223.
- Salehi PP, Jacobs D, Suhail-Sindhu T, et al. Consequences of medical hierarchy on medical students, residents, and medical education in otolaryngology. Otolaryngol Head Neck Surg. 2020;163:906-914.
- Lomis KD, Carpenter RO, Miller BM. Moral distress in the third year of medical school: a descriptive review of student case reflections. Am J Surg. 2009;197:107-112.
- Troughton R, Mariano V, Campbell A, et al. Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy. Antimicrob Resist Infect Control. 2019;8:116.
- Chiu PP, Hilliard RI, Azzie G, et al. Experience of moral distress among pediatric surgery trainees. J Pediatr Surg. 2008;43:986-993.
- Martinez W, Lo B. Medical students’ experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42:733-741.
- Chapter 1. opinions on patient-physician relationships. American Medical Association website. Accessed on August 9, 2022. https://www.ama-assn.org/system/files/code-of-medical-ethics-chapter-1.pdf
Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.
The Ethical Dilemma of Treating an Attending
Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.
This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?
Ethics Curriculum for Residents
Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.1
One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.2 These themes must be considered in different permutations throughout ethical conundrums.
In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al3 shows. The patient’s autonomy allows them to choose their treating provider.
However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.4 Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.
The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.
Navigating the Ethics of Treating Family Members
The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.10
The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.10 If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.
Treating Nonsupervisory Attendings
In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.
Final Thoughts
Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.
Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.
Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.
The Ethical Dilemma of Treating an Attending
Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.
This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?
Ethics Curriculum for Residents
Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.1
One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.2 These themes must be considered in different permutations throughout ethical conundrums.
In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al3 shows. The patient’s autonomy allows them to choose their treating provider.
However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.4 Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.
The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.
Navigating the Ethics of Treating Family Members
The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.10
The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.10 If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.
Treating Nonsupervisory Attendings
In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.
Final Thoughts
Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.
Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.
- Dermatoethics. American Board of Dermatology website. Accessed August 9, 2022. https://www.abderm.org/residents-and-fellows/dermatoethics
- House JB, Theyyunni N, Barnosky AR, et al. Understanding ethical dilemmas in the emergency department: views from medical students’ essays. J Emerg Med. 2015;48:492-498.
- Unruh KP, Dhulipala SC, Holt GE. Patient understanding of the role of the orthopedic resident. J Surg Educ. 2013;70:345-349.
- Grandhi R, Grant-Kels JM. Naked and vulnerable: the ethics of chaperoning full-body skin examinations. J Am Acad Dermatol. 2017;76:1221-1223.
- Salehi PP, Jacobs D, Suhail-Sindhu T, et al. Consequences of medical hierarchy on medical students, residents, and medical education in otolaryngology. Otolaryngol Head Neck Surg. 2020;163:906-914.
- Lomis KD, Carpenter RO, Miller BM. Moral distress in the third year of medical school: a descriptive review of student case reflections. Am J Surg. 2009;197:107-112.
- Troughton R, Mariano V, Campbell A, et al. Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy. Antimicrob Resist Infect Control. 2019;8:116.
- Chiu PP, Hilliard RI, Azzie G, et al. Experience of moral distress among pediatric surgery trainees. J Pediatr Surg. 2008;43:986-993.
- Martinez W, Lo B. Medical students’ experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42:733-741.
- Chapter 1. opinions on patient-physician relationships. American Medical Association website. Accessed on August 9, 2022. https://www.ama-assn.org/system/files/code-of-medical-ethics-chapter-1.pdf
- Dermatoethics. American Board of Dermatology website. Accessed August 9, 2022. https://www.abderm.org/residents-and-fellows/dermatoethics
- House JB, Theyyunni N, Barnosky AR, et al. Understanding ethical dilemmas in the emergency department: views from medical students’ essays. J Emerg Med. 2015;48:492-498.
- Unruh KP, Dhulipala SC, Holt GE. Patient understanding of the role of the orthopedic resident. J Surg Educ. 2013;70:345-349.
- Grandhi R, Grant-Kels JM. Naked and vulnerable: the ethics of chaperoning full-body skin examinations. J Am Acad Dermatol. 2017;76:1221-1223.
- Salehi PP, Jacobs D, Suhail-Sindhu T, et al. Consequences of medical hierarchy on medical students, residents, and medical education in otolaryngology. Otolaryngol Head Neck Surg. 2020;163:906-914.
- Lomis KD, Carpenter RO, Miller BM. Moral distress in the third year of medical school: a descriptive review of student case reflections. Am J Surg. 2009;197:107-112.
- Troughton R, Mariano V, Campbell A, et al. Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy. Antimicrob Resist Infect Control. 2019;8:116.
- Chiu PP, Hilliard RI, Azzie G, et al. Experience of moral distress among pediatric surgery trainees. J Pediatr Surg. 2008;43:986-993.
- Martinez W, Lo B. Medical students’ experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42:733-741.
- Chapter 1. opinions on patient-physician relationships. American Medical Association website. Accessed on August 9, 2022. https://www.ama-assn.org/system/files/code-of-medical-ethics-chapter-1.pdf
Resident Pearls
- Dermatology residents should not perform total-body skin examinations on or provide long-term care to attending physicians that directly oversee them.
- Residents should only provide care to their attending physicians if the attending’s life is in imminent danger from delay of treatment or if it is a self-limited, minor problem.
