What If Patients Say No?

By: Olle ten Cate, PhD

In this blog I want to focus on the position and autonomy of patients in the clinical training environment and signal a lack of guidelines to navigate the interests of all parties involved.

In teaching hospitals, entrustment with patient care tasks can be regarded as a six-way street. Trainees providing care must be trusted by their supervisors and by patients, i.e. those under formal care by supervising clinicians. Supervisors must be trusted by their trainees, attending physicians must also be trusted by their patients, i.e. to organize the care in a best possible way, including the engagement of trainees and other care providers, and patients must be trusted to cooperate with care providers; both with their own attending physician and with any auxiliary trainees. These streets reflect transactional dynamics that puts one party in the position of some vulnerability, having to rely on the other’s competence and benevolence to provide a service.(2)

The walkability of the streets is not similar in all directions. Trainees who are asked (and trusted) by supervisors to care for patient usually cannot say no (they are paid and the activity counts towards their educational progress). A supervisor, asked by a trainee to come and help out under ‘indirect supervision’ may say no, but only if they are convinced that this decline does not hurt the trainee or the patient. Patients usually have the legal possibility to say no if asked to be attended by a trainee but will often not be aware of the difference between a senior medical student, a resident physician, a fellow in subspecialty training, or a fully licensed and certified attending staff member. And, they may not be aware of any option to say no. If patients en masse would say no to contributing to training, much of training and much of health care would stop. In many countries, a substantial amount of health care is provided by trainees who are not certified to work unsupervised. Strikes of medical trainees, as recently happened in the UK and South Korea, have shown how severely disrupted health care can become without trainees. Is patient cooperation with education on the decline? We don’t know, but some authors report frequent refusal.(3)

Triggered by a workshop during the Association of Medical Schools in Europe annual conference in October 2025 in Olomouc, Czech Republic, on bioethics of patient involvement in education (using a UNESCO framework(4)), it struck me that patients’ role in consenting to be cared for by a trainee was not discussed. I decided to devote an upcoming editorial to it.(5) Concurrent with it, The Clinical Teacher published the above perspective paper on patient denial of engagement in education.(3) An ICBE blog on the topic seems timely. Patient consent with medical procedures and treatments is well founded in UNESCO’s rules, but the consent to be attended by a trainee is rather implicit. It is common to ask patient consent for explicit educational events, such as bedside teaching, skills lab training, occasional curriculum development committees (6,7), but the vast majority of instances of patient involvement in education happens when they are attended by a trainee instead of by a licensed and certified professional is the only patient contribution to training.

Why is this a timely topic? The philosophy of CBME, as operationalized through entrustable professional activities, involves, prominently, the explicit entrustment with patient care tasks during training. The educational and motivational value, patient safety, and supervision level associated with entrustment are themes that begin to feature prominently in the literature. The role of patient consent in the triad of supervisor-trainee-patient has not received much attention.

Educators and hospital contexts have, usually unwritten, rules and habits (such as “all patients who walk in a university medical center should anticipate being attended by supervised trainees”). Such rules belong to the domain of bioethics.  UNESCO’s bioethics rules include basic rights of autonomy, active consent, and a reasonable balance between benefit and harm and thus the right to say no. Saying no may serve an individual interest but collide with a collective interest of educating future professionals. It is not likely that a patient would easily consent to being the first patient for a trainee to perform a specific procedure, yet this regularly happens–and must happen. Training is impossible without “first times”—first time with supervision, first time without supervision. In most cases, patients will not know this.

Here is where we have a lack of bioethical guidelines, to help clinician educators, trainees and patient, to navigate diverse interests to optimize the six-way streets of trust, as a condition for medical training, of for that matter, any training of health care professionals with patient care tasks. Supporting the call in my editorial, I would like to invite HPE scholars and ethicists to develop such guidelines, answering questions like:

• When and how should patients be informed and when not?
• Can collective information and implicit consent replace individual consent?
• Should patients be aware that a trainee has received a summative entrustment decision to act with only distant oversight, received from a competent body (a clinical competency committee)?
• What can a clinical supervisor do when a patient says no?

As CBME and explicit entrustment decisions become prevalent, continued reliance on implicit consent and local custom feels increasingly uneasy. If trust in clinical education is indeed a six-way street, then it might be time to make its ethical rules explicit and help hospitals, educators, trainees and patients navigate this area; it may be time to establish guidelines.

Refrences:

1. Gin BC, Holzhausen Y, Khursigara-Slattery N, Chen HC, Schumacher DJ, ten Cate O. Theoretical foundations of trust and entrustment in health professions education. In: ten Cate O, Burch VC, Chen HC, Chou FC, Hennus MP, editors. Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education. Ubiquity Press; 2024. p. 35–50.
2. Mayer RC, Davis JH, Schoorman FD. An integrative model of organizational trust. The Academy of Management Review. 1995 Jul;20(3):709–34.
3. Gitti SA, Al-den SSB, Abbas AF. When patients say no: rethinking refusal in bedside medical education. Clin Teach. 2025;22(6):e70235.
4. Matsuura K. Universal Declaration on Bioethics and Human Rights. Paris: UNESCO; 2005.
5. ten Cate O. Bioethics of patient involvement in clinical education, a call for guidelines. Journal of Health Professions Education and Innovation. 2025 Nov 1;2(4):1–3.
6. Eijkelboom C, Brouwers M, Frenkel J, van Gurp P, Jaarsma D, de Jonge R, et al. Twelve tips for patient involvement in health professions education. Patient Educ Couns. 2023 Jan;106:92–7.
7. Young M, Kline C, Towle A. A checklist for involving patients in educational activities. Clin Teach. 2025 Dec;22(6):e70282.

About the Author:

Olle ten Cate, PhD, is an emeritus professor of medical education at University Medical Center Utrecht, the Netherlands.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The University of Ottawa . For more details on our site disclaimers, please see our ‘About’ page