Hospital-based education of future specialists is important to acquire knowledge, skills and abilities, professional competencies and to form clinical thinking. Transfer of professional medical experience occurs simultaneous to the development of communication skills which are required to deal with relatives, comprehension of how the normal standards of medical deontology are implemented in real practice and how important the effective therapeutic alliance is while interacting with the patient.

Though bedside training is a long-standing tradition of medicine, the origins of which are associated with the Ancient Greek Healing Practices, it is not always understood and supported by patients and their relatives, and requires students to get more familiar with ethical standards regulating similar education and their behavior within a medical group and institution.

The goal of the article is to review ethical aspects of bedside training.

THE HISTORY OF THE PROBLEM

Bedside training of future doctors is associated with the Ancient Greek Healing Practices and medicine of peoples of the ancient and medieval East. However, during the Middle Ages, medicine in Europe was taught through books approved by religious leaders. The situation changed during the Renaissance when Giovanni Battista Montano from the University of Padua began implementing clinical (bedside) teaching claiming that ‘teaching is possible at bedside only’. Nevertheless, it was merely book learning, as in European medical education, the effect of scholasticism persisted for quite a long time.

The key role in the development and implementation of clinical teaching was played by the University of Leiden (the Netherlands) and Boerhaave Hermann who was in charge of the University Hospital. He introduced bedside, or clinical, teaching for medical students. . Boerhaave was a teacher of Nicolaas Bidloo from Amsterdam who was responsible for the formation of higher medical education in Russia. In 1702, Bidloo was invited to Russia and became a personal physician of Tsar Peter I. In 1707, he was the head of the first hospital school in Russia opened in Moscow at the initiative of Peter I [1].

In the beginning of the last century, Veresaev VV in his ‘Memoirs of a Physician’ paid attention to the challenges of medical education in Russia: ‘The knowledge obtained by me at the University constituted the chaotic terrain, which I couldn’t navigate and in front of which I stood in utter helplessness. The mere science presented in books and not tested by me in real life cheated on me over and over again; its solid and fixed forms could not accommodate a new life; and I never knew how to make these forms elastic and mobile. I was always wrong in my attempts to predict the further course of the disease and was afraid to show my face to patients’ [2]. Discussing the problems of professional medical training in his book, Veresaev VV showed the role of ethics in the development of a future specialist who should not only feel compassion and sympathy to the patient, but also be able to assess himself properly, understand and admit own incompetence and even mistakes. It is not accidental that the writer mentions the book by Pirogov NI ‘The Annals of a Surgical Hospital’ when the issue of a medical mistake has been raised as a matter of concern. Meanwhile, Veresaev VV noted as follows: ‘No matter how sad it is, but we should admit that our science is still free of ethics. What we really have to deal with is specialized corporate medical ethics that regulates the attitude of doctors to the public and their colleagues’ [2].

The circumstances described by Veresaev VV did not go through immediate changes. However, the medical community gradually recorded the basic standards of medical ethics within the documents, and ethical codes in particular. The ‘Ethical Code for Medical and Pharmaceutical Students’ is one of the documents with interesting provisions related to hospital-based education [3].

THE ETHICAL CODE FOR MEDICAL AND PHARMACEUTICAL STUDENTS

Hospital-based education imposes certain obligations upon students. The obligations are associated with compliance with the standards and rules of a medical institution, and communication with teachers and other medical workers. The Ethical Code for Medical and Pharmaceutical Students was developed by members of the Council of Medical and Pharmaceutical Universities of Russia and adopted in 2015 during the IV All-Russian Forum of Medical and Pharmaceutical University Students [4]. The Ethical Code (EC) consists of 5 articles; it is mainly oriented at high morality, medical ethics and deontology, dignity, conscience and distinguished title of a medical worker. In our opinion, the most important provisions of the EC regulating the education of students at a hospital were presented in some articles.

In article 3, they claim that the relations between students, teachers, hospital employees and patients should be based on ‘mutual respect and cooperation, tacts and correctness, politeness and mutual aid…’. Any forms of humiliation of honor and dignity, physical and mental personal violence, use of obscene, curse and slang language while talking to patients, senior colleagues and other students are prohibited. Maintaining cleanliness of the hospital is no less essential.

Article 4 regulates the student’s appearance. It should correspond to standards and operating conditions of medical institutions. Students should wear clean white lab coats or medical costumes and look professional. Wearing a medical cap and spare shoes is essential as well. Girls should tie their hair back. It should be noted that ‘sharp odor cosmetics and perfume, gel manicure, unproper (large) gold/silver ware, fashion jewellery, and high heel shoes are not ethically approved’.

Article 5 gives us an idea of how to behave and interact with employees of a medical institution. A special attention is given to being polite and displaying mutual respect. Thus, while meeting employees of a University department or a medical institution, a student always greets the persons even if he does not know them personally. It is also necessary to respect a patient’s honor and dignity and the right to personal secrecy. Always remember about your patient’s relatives and try to understand their feelings.

Thus, it is extremely important that students of clinical hospitals should follow the EC and related rules, as a physician should not only accumulate medical knowledge but also have high moral principles. Nevertheless, patients are not always ready to interact with students who undergo through training.

A HOSPITAL AS A CLINICAL BASE OF THE UNIVERSITY: INTERACTION WITH PATIENTS.

Not all patients are aware of the fact that while being hospitalized, they sign documents stating that a medical institution is a clinical base of the University. Thus, students of the medical university can attend and examine patients freely, and collect the history. Students are commonly rejected by patients who do not agree to be examined (the problem is very pressing in case of a female patient and a male student). But patients are human, too. They can get tired (especially when one patient is visited by many groups of students), feel bad, and be at a loss or sorrow because of their disease. In our opinion, there is a solution to the problem.

1. When patients are hospitalized, the hospital employees should stress that a hospital is a clinical base of the University and that students should stay at wards, collect history and carry out an examination.
2. Students should be presented to the patients as future doctors who possess the necessary knowledge, follow deontology and can keep the medical secret.
3. Students should be explained why working directly with patients is important for them. Theoretical knowledge with no practical experience would prevent them from being good specialists who will treat the patient, friends and relatives.
4. Students should also be able to put themselves into the patient’s position: understand the patient’s condition, respect the person’s personal space, visit patients in small groups without making them feel uncomfortable.

The provisions should be followed even if they are not reflected in the EC for Medical and Pharmaceutical Students.

HOSPITAL AS A CLINICAL BASE FOR PRACTICAL TRAINING: INTERACTION WITH MEDICAL PERSONNEL.

Modern medical education is impossible without visual memorizing and practical experience. You can read a book, articles, scientific research, keep repeating symptoms and syndromes, clinical picture of the disease, but only real bedside experience can promote long-term memorization. It often happens that students may also have difficulties while communicating with hospital personnel. For instance, students don’t adhere to the hierarchical order or come to the hospital when they do not feel well without even wearing individual protection means. It can produce a negative effect not only on a student who violated the rules but also on his colleagues. Thus, students can be prohibited to visit patients and stay in wards. What measures can prevent possible educational problems?

1. A teacher should be open to professional communication explaining treatment specifics especially when students feel that the treatment strategy is wrong and when they want their mentor to make the situation clearer; explaining how to communicate with patients and their relatives; explaining the hospital rules, including evident aspects which are missed out such as neat clothing, punctuality, and subordination in dealing with nursing staff. It is important to remember that students, patients and hospital employees are eligible for a kind attitude and respect.
2. Sick students should stay at home and not to expose patients to additional risks. However, a missed class means that a student can’t deal with the problem in practice, and examine a patient. The gap should be filled by agreement with a teacher or treating physician, and the possibility will be a significant factor of compliance with sanitary and epidemiological standards. It is also essential that the students should understand that the situation is exceptional and should not trespass upon the attitude of a teacher or treating physician.
3. Teachers who are eager to share their experience in solving moral and psychological problems faced by some students are playing an important role. For instance, severe obstacles for proper examination can include disgust or lack of patience while talking to suspicious or elderly people, which may further make communication difficult as the patient will feel the bad attitude and will doubt whether the treatment was proper, etc.

PROFESSIONALISM IN MEDICINE AND EDUCATIONAL CHALLENGES AT A HOSPITAL

During the last decades, the issues of professionalism in medicine attract the attention of many researchers who advert to ethical aspects of a physician’s activity. In this perspective, professionalism can be considered as a physician’s preparedness for responsible work such as being integral while performing own duties, displaying high standards towards own knowledge, professional competencies and self-education, and taking into account ethical aspects while performing medical procedures in clinical practice. Academician Petrovsky BV stressed that ‘personal responsibility should be based on the constant strive of a physician towards theoretical knowledge and improvement of practical skills, continuous upgrade of professional skills by using the critical analysis of observations, examination of mistakes, learning from the older colleagues and reading literature, and raising ethical and deontological standards’ [4].

A professional should be able to listen to a patient, explain the situation clearly and to prove conclusively the need for certain medical appointments. It is essential to understand the specifics of various areas of medicine. The fact is stressed by academician Chuchalin AG in his ‘Interview with a physician’ by suggesting the bases for development of the individual diagnostic algorithm for every doctor. Academician Chuchalin AG emphasizes the importance of bioethics for education of a future medical specialist: ‘A modern doctor is, first of all, a well-educated, highly competent and thinking specialist with high moral standards’. What should a physician’s mission be like in Russia? A physician should protect health, display deep respect for human dignity, personality and life. Those who adhere to traditional ethical values commonly reinforce and develop traditions that promote sustainable development of mankind’ [5].

CONCLUSION

Historically, the first principle of medical ethics is primum non nocere(‘first not do any harm’). Students will learn about it during the first stages of their education and, primarily, in the course of bioethics. The norms and standards of bioethics become ethical guidelines that determine the further bedside education. In the process of education, students of medical universities urgently need the practical activity. They learn to contact with different patients, balance between a patient’s fear and concern, convince that the selected therapy is rational, help a human being trust the doctor with the smallest nuances of life, which can influence the diagnosis, select the laboratory and instrumental diagnostics and treatment scheme. While communicating with patients, students understand the power of a word: it can help, motivate a patient for a positive outcome and cure him. That’s why a doctor needs to be proficient in speech, have proper communication skills to make a good impression on patients and relatives, making them open up and trust patients.

Future physicians need to see on a daily basis how practicing physicians implement the standards of bioethics, learn from their experience and use it subsequently. Theory means nothing without practice just like pure practice means nothing without theory. It is important that students should be aware of the responsibility of the selected path. Only in this case the required result can be obtained.

Bioethics forms the basis of a medical student’s life. Without the basis, it is difficult to become a professional in the future as successful doctor-patient communication is impossible without taking into account its bioethical, psychological and legal aspects. A student should know bioethical standards. The he will be able to make important steps on the path of learning the healing arts. According to Academician Chuchalin AG, ‘the world of a doctor is complicated and often tragical, full of painful concern for own mistakes and constant search for solutions, which sometimes determine a human fate. Ethics and deontology are the essential features of a physician’s moral activity. While speaking about ethical issues, we first of all mean the welcoming nature of a physician’s activity. Empathy helps to implement the ethical standards of healing. A doctor has to deal with ethical issues related to the health values of a human every day; he takes a decision assessing what is good and what is bad’ [6].