What Should Medical Students be Called--Revisited

This posting is a revisiting as an ethical issue of a situation in medical education which was first considered here on August 7, 2004 (scroll down this page if you want to read it.) The view today is written by a medical student herself for a class discussing ethical issues. Jennifer Piel is a second year medical student at the University of Southern California Keck School of Medicine. Jennifer will have any comments on her essay by visitors to this blog accessible to her. Thanks Jennifer for allowing me to post your words here. ..Maurice.

A problem that I have seen repeatedly at the hospital and in situations in community practice is the scenario in which a practicing physician introduces a medical student as a “doctor.” Addressed here are some of the ethical issues presented by the scenario.

Students Placed in Awkward Position

When a supervising physician introduces a medical student as a “doctor,” it places the student in an awkward position. Most likely, a physician makes these introductions to encourage trust between the student and patient. Nevertheless, it places the student in an uncomfortable position to correct the physician and inform the patient of the mistake.

Although the student should take responsibility to correct the statement of mistaken identity, it may be difficult for the student to confront his/her supervisor, particularly when the physician would feel that the student is undermining his/her authority or intentionally being confrontational. The student may be correct in recognizing an ethical conflict, but feel prevented from addressing the issue out of fear of reprisals from the physician.

Similarly, the student is placed in the difficult position of addressing the issue with the patient. Some students may fear that correcting the issue of mistaken identity will result with the patient refusing care by the student. However, even if some subset does refuse student care, many patients will likely be quite willing to allow appropriate student involvement in their care, In my opinion, the fact that some patients decline student care is no justification for deliberately misleading them.

Moreover, clarifying the mistake with the patient will likely preserve trust between patient and student, if the patient realizes that the student is trying to be honest and straight-forward.

Effect on Patient Decisions

When a medical student is introduced as a doctor, particularly when the student is going to be involved in the patient’s care, it prevents the patient from making informed health care decisions. Not only does this scenario present ethical concerns, but legal concerns as well.

The first issue here involves the student holding himself/herself out as a physician. To respect patient decision-making autonomy, there should be a free exchange of material information between the patient and student. Autonomy is a key ethical consideration, focusing on the right of self-determination. It is grounded in the idea that patients should have control over their personal decisions. Accordingly, it is appropriate to disclose to the patient that the physician-in-training is, in fact, a student.

It may be argued that the principle of beneficence should be the key ethical consideration in situations involving medical care. The principle of beneficence commands that benefits to individuals and society be maximized and that harms be minimized. Under this principle, one could argue that it is in the patient’s best interest to identify the student as a physician because, then, the patient is not burdened with potentially troubling information. Some patients are likely to consent to student care, but subsequently feel uncomfortable with the student’s level of knowledge or skill. This argument begs the conclusion that, because the patient would have consented to the student care, the patient is subject to less harm when the student’s true identity is withheld.

A number of flaws exist with this latter line of reasoning. To begin with, it is naïve to suggest that we could benefit a patient by withholding relevant information. Patients would likely prefer that their health care professionals are honest with them. As mentioned above, the patient may justifiably feel disrespected. This could cause the patient to mistrust other members of the hospital’s staff. Additionally, to even minimally respect a patient’s autonomy, health care providers should give the patient the option to refuse care. Even patients that would consent to student care should be asked.

In situations where a student is held out as a doctor, a second issue concerning the patient’s decision-making is brought into question. In this situation, the patient will not know to ask, nor be informed, whether the procedure or care in question is ordinarily provided by a student. Like the failure to disclose the student’s true identity, failure to adequately provide the patient with this information inhibits the patient from making a fully-reasoned decision. It could be that the patient would have agreed to the student performing the procedure, subject to certain conditions, such as an experienced physician being present or that the procedure be conducted in a particular manner. Alternatively, the patient might have agreed to student participation, but, upon hearing that a particular procedure is not a routine responsibility of medical students, decide that he rather have a physician perform the procedure after all. This illustrates the situation where the patient is unaware that the student’s competency is even a question to consider.

In terms of the law surrounding informed consent, physicians have a duty to disclose and ensure that patients understand all information material to the patient’s decision to undergo or deny particular medical attention. A physician who fails to fulfill these requirements may face liability under a simple negligence theory. Further, medical personnel who perform medical procedures without gaining proper consent may be liable for civil battery. Although courts disagree as to whether informed consent cases should be evaluated from a patient-oriented or physician-oriented approach, it is risky in either case to mislead a patient about the identity and skill-level of an individual treating the patient. This information is likely material.

Facilitating the Unauthorized Practice of Medicine

As a society, we have established regulations to prohibit non-physicians from practicing as doctors. We do this to protect the public from incompetent or unethical performance of medical services. It further serves to protect the integrity of the medical profession. Because patients often cannot distinguish between their doctors, medical students, and other health care personnel, it seems imperative that providers make specific efforts to minimize any confusion.

Although students practicing under the supervision of a licensed physician are generally protected from claims of unauthorized practice of medicine, this may not hold true where a student holds himself/herself out as a physician and/or the student is not adequately supervised. A physician may not delegate ultimate responsibility for providing medical care to an assistant. Such delegation is appropriate only when it is consistent with the assistant’s training and education.

The legal case of Oliver v. Sadler (Jury Verdicts Weekly, Oct. 7, 1994) involves a similar situation to the illustration presented here. In that case, a patient was seen by a physician assistant. When the treatment proved harmful, the patient sued Dr. Sadler, in part, because he misrepresented his physician assistant as a physician. It was argued that the patient assumed the physician assistant was a doctor because he wore a white coat and had a stethoscope. This presents the very picture of medical student and underscores the need to accurately identify for the patient the individuals who are involved in the patient’s care. Isn’t it unethical to foster patient confusion?

This essay highlights some of the ethical issues faced when a student is introduced to a patient as a “doctor.” It is unrealistic to expect that this situation will never again occur. Accordingly, it is advised that students and their supervising physicians speak openly about the student’s status, role, and responsibilities before being introduced to a patient.