Bioethics Discussion Blog: Shadowing a Doctor: A Benefit or Harm?

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Monday, January 13, 2014

Shadowing a Doctor: A Benefit or Harm?






Entering a physician's office for a visit and examination may allow you to be a participant in a medical exercise called "pre-medical shadowing".  This means that, hopefully with your full informed consent,  a college student called a "pre-med student" who has been studying courses to apply to medical school, will be present to learn what the practice of medicine is all about as seen within the office of a doctor in practice. Some medical educators believe that if  these college students "shadow"(watch)  professional physicians at work they will get some insight into the profession before applying to medical school and their education in this regard may be of some value. 

Though, as a medical educator and physician myself, I find some value in this "shadowing" I do have some concerns and I expressed my opinion to a medical education website as follows:

Does anyone think that "clinical shadowing" by pre-med students will, whatever the benefits from the experience, also instill elements of the "hidden curriculum" taught to 3rd and 4th year students and beyond   even before experiencing the more "humanistic" learning provided 1st and 2nd year students? Or am I becoming overly concerned?

The "hidden curriculum" is defined as being the education of these students and residents by experience mature superiors who promote their own view of medical practice in a way different and perhaps more organizational and bureaucratic but perhaps less humanistic from what their subjects learned in the earlier years of medical school.

A medical educator responded to the website with the following comment:

Maurice's question is a good one, and one on which my colleagues and I have been reflecting.  We have seen evidence of the interference of the shadow in the ways M1 and M2 students make patient notes, using abbreviations that are no longer acceptable or are short-hand used by physicians who learned the longer versions first.  We have also seen evidence in the ways in which students talk about patients: non-compliant; drug seekers; physician-centered, disease-first speak rather than patient-centered, people-first speak.  

The phenomenon seems to be a bit akin to rituals of tribal acceptance.  Medical students are in school to become part of a given subculture, the tribe of medicine.  They may have different reasons for doing so, but the end point is the same: join a culture with its own language, behaviors, norms, and so on.  If they shadow members of this culture, tribal elders who were trained to behave in certain ways, then go to an educational institution that attempts to tell them to behave otherwise, it would seem rational for them to comply with the institution externally but with the tribal elder internally.  The elder is practicing in the field and therefore seems to have more social capital than institutional pre-clinical educators.  

This is a particularly interesting phenomenon given that medical schools are working on creating future leaders for a medical culture that is itself in the midst of an intense transformation.  The tension between tribal tradition and transformational innovation is palpable, manifesting in a variety of ways including the necessary use of practicing elders as faculty and mentors for said future leaders.   

Shadowing may help pre-matriculants to get a better grasp on the daily routines of the profession, but it may also be contributing to a prior knowledge base that hinders development of the medical culture. 

What I find of importance in this response is regarding the possible effect of this "shadowing" on inhibiting  the medical profession to advance medical practice from "old tribal tradition" to new ways, in new times, to improve the patient's value from the doctor-patient  relationship.  

There is much more to consider regarding this issue of  "shadowing" by some undergraduate college student including issues of patient privacy with regard to both sensitive history taking, physical examination and the physician's discussion of emotionally sensitive conclusions with the patient with a student in attendance.

I would be most interested to read what my visitors here think about "shadowing" by pre-medical college students.   ..Maurice.

Graphic: From Google Images.

18 Comments:

At Tuesday, January 14, 2014 11:40:00 AM, Anonymous Anonymous said...

I think there are several issue starting with "informed consent" that I will come back to.

I don't know how you get around the tribal indoctrination of the old ways transferring. It happens in any institution. In my business I am trying to figure out as we prepare for a generational transfer how to not met my experience from the past hold back the incoming generation. My idea of how to do business is largely formed from my 30+ years of business practices and systems. To only pass that on is to leave the ill prepared with outdated information and practices. How do we get around that? We don't even know what we don't know so how do we teach it. It is natural, we are attempting to deal with it by soliciting new and younger thought from team members within and outside of their area of expertise. Not sure how you do the with the M1 or M2 unless you partner them with some "newer" providers.
The other take away is the need to fit in and the effect of trying to fit into the institutions boundaries. This really does come back and reinforce my view that medicine is a us and them mentality. Where a provider may identify internally with a patient, they are rewarded or punished how well they identify and fit into the external protocol for behavior provided by the institution. Thus I challenged when the institution's goal is to get patients to participate in shadowing, will the institution really support informed consent, which means truly giving the patient the right to decline, internally as well as externally. I think consent will be sought in a manner that meets the institutions need, even if that means compromising the informed portion.
That said there is the possibility for a win win in shadowing. It starts with truly informed consent by letting the patient know early in the process, perhaps when they are filling the sign in, and allowing them to accept or decline with as little pressure as possible, i.e. a check off of a box rather than when providers are face to face. Then, if the M1 and M2 are allowed the time to interact with the patient informally while the MD goes on about the physical side, they might get some insight from the patient the MD would not even notice. So I don't think it is good or bad, I think it depends..don

 
At Tuesday, January 14, 2014 12:28:00 PM, Blogger Maurice Bernstein, M.D. said...



What is being discussed here is physician "shadowing" by college undergraduate students who are not yet part of a medical school teaching program. This practice has been to some extent encouraged by medical schools as a learning experience of what the medical profession entails.

I believe the instructor who had responded referred to M1 and M2 as first and second year medical students respectively and NOT undergraduate college students. "Shadowing" as part of a medical student's education is not unusual and is carried out in many ways but in educationally constructive ways. The concern was that some of these medical students were already demonstrating "casual" documentation assumed to be related to their college "shadowing" experiences.

What has also been mentioned in the literature is even high school students doing the "shadowing" for a very early experience the medical career.

The important issues created by "shadowing" beyond an college student learning professional "casual" behavior as noted above but also the effect of the activity on both the doctor and patient's reactions despite the fact that the patient gave some sort of informed consent for the student's presence. There may be hesitation on the part of both doctor and patient to reveal or expose history, physical exam or finding while the college student is present. After all, the college student is neither a medical student nor a physician. ..Maurice.


 
At Thursday, January 16, 2014 7:07:00 AM, Blogger R Williams said...

I would be interested to know what percentage of students are dissuaded from the profession due to doctor shadowing experience. If even a small number find that it deters them from the career then I think that shadowing is probably a necessary evil. The decision to go to medical school is a big commitment. In my opinion it's a bigger commitment than getting married, because the doctor-to-be is likely to spend more waking hours with his or her profession than spouse. With a marriage you can always change your mind and get divorced after a couple of years and not have a six-figure student loan debt and no real job skills to pay it off with. People recognize that it's insane to marry someone you haven't gone on a few dates with, but most people probably think nothing of a twenty-one year-old deciding to go to med school without any experience or first-hand knowledge of the profession, probably because most people don't fully recognize the bigger commitment it takes to become a doctor (as opposed to an engineer or accountant).

Shadowing is a good opportunity for a pre-med but I personally think it's classist BS for schools to favor a student that has a couple hundred hours of shadowing (or volunteer) experience over a student who had to work at Burger King for four years while taking a full course load. I still remember when I applied to my undergrad college. I was a senior in high school taking five courses for college credit while waiting tables thirty hours a week. When I applied to the school I ended up at, they had a a long section on the application for extracurriculars that had space for you to put how many hours you spent with each E.C. For the "work" section, they just had three lines to list all the jobs and positions you had held. I had been working since I was fourteen and could barely squeeze everything in there. Now I'm applying to PA schools and I'm in a similar predicament. I haven't shadowed PAs partly because I've been working while studying and partly because I just flat-out don't know any PAs. I know all this isn't directly related to the substance of the post, but I feel like the preference shown to students who shadow is sort of like the unpaid internship. It's a way for kids from wealthy or connected families to get a leg up on their poorer peers, and I get the sense that admissions committees tend to be composed more of people from wealth than people from poverty.

This post misses one big motive for a student using "the hidden curriculum": the desire to seem more "in the know" than his peers (or her peers, but I would bet money that it's male students who usually do this). I took an EMT-B course once and this sort of behavior was so pronounced that it was obvious what motives were. All throughout class there were these guys making every effort to show-off their inside knowledge. It's a way to seem hipper, cooler, and more impressive than everyone else. A savvy educator could effectively inoculate against this sort of behavior with a few words at the beginning of class.

Again, though, if shadowing helps pre-meds make a more informed decision about going to med school, then it should stay. On the other hand, if anyone could come up with reliable data showing that the shadowing experience has no impact on pre-med's decisions, then there's a very solid argument for doing away with the practice altogether, for the reasons Dr. B already mentioned. Until then, it's up to medical educators to directly address and confront the complications that result.

 
At Monday, January 20, 2014 11:09:00 PM, Anonymous Anonymous said...

I think that one should define "shadowing" more thoroughly. If this shadow is to accompany a physician who is examining patients, I personally would not accept that. The student needs to demonstrate maturity by completing some college first. I disagree with R Williams that deterring students is good. Even if a student drops out at some time, there is benefit in the student's education. That student could still become a nurse, PA, or a DVM. Gerald

 
At Monday, January 27, 2014 7:44:00 PM, Anonymous Anonymous said...

I definitely oppose the "shadowing" of undergraduates - I don't believe that they have been educated in such areas of confidentiality and may be too young to understand both the medical and emotional aspects of the medical visit. Next, I have had too many medical students introduce themselves as "doctor" and that is how they are going to start a trusting relationship, they can do it elsewhere. Lastly, I am not sure hjow the MD mentors are selected- what sensitivity and style of care, treatment, or value of individuals do they bring to examining room. A good doctor can be a good teacher. But a patronizing, self centered individual may give the wrong message to a medical student who is developing his own style. CBN

 
At Monday, January 27, 2014 8:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Excellent point. I am not sure how any medical school has control over which physicians the undergrad student will shadow.

As an instructor for first and second year medical students, we instruct them to identify themselves to the patient as a "medical student" and not "student doctor" or simply (heaven-forbid!) "doctor". ..Maurice.

 
At Sunday, February 02, 2014 3:14:00 PM, Blogger Hexanchus said...

This is a no-brainer.

I can't conceive of any possible situation where the presence of an undergrad student shadowing the provider would be of any possible benefit to the patient.

If the patient is given full and complete disclosure and chooses to consent to allow the shadowing student to be present, that's up to them. In any other circumstance, allowing shadowing is unethical, and violates the rights of the patient. FWIW, IMHO this applies medical/nursing students or any other trainees as well.

For any test, treatment or procedure, a patient should always be informed who will be present, their true title/qualifications and what their role will be.

Hex

 
At Sunday, February 02, 2014 9:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Hexanchus, I agree. Full understanding by the patient of a student's presence and role is critical and I would say, in addition, the patient should be informed in what way, if any, the student's presence would affect the communication and examination of the visit. I am concerned too about the presence of an undergrad college student from the point of view that the student may pick up also "physician bad habits" as part of the experience.

I disagree with Hex about the presence of medical school students themselves in "shadowing" their instructors. Such a visit by a medical student, tailored to the exposure to the best of medical professionalism is an important educational experience for them. ..Maurice.

 
At Saturday, February 22, 2014 12:30:00 PM, Anonymous Anonymous said...

"I disagree with Hex about the presence of medical school students themselves in "shadowing" their instructors. Such a visit by a medical student, tailored to the exposure to the best of medical professionalism is an important educational experience for them."

Again...we are talking about what is best for the student and not the patient. The patient is being asked to give up the only personal time they may have with their doctor to discuss all of their concerns and for what may very well be another year before that happens again. Why are patients being asked to sacrifice that critical personal time? What may be useful to the student may be a hindrance to the patient.

Where is the patient benefit?

Others may not agree, but my time with my doctor is not a learning opportunity for others. I pay for my doctor's time....and she/he has no right to ask me to share that personal time with anyone else.

Suzy

 
At Saturday, February 22, 2014 9:44:00 PM, Blogger Maurice Bernstein, M.D. said...

Suzy, there would be no way to provide thorough medical education to a medical student without the patient "sharing personal time" with the student. There are plastic models of patients bodies. There are "mechanical" patients. There are video scenarios of patients. There are teachers who are "standardized patients" but not of these "patients" provide the full and necessary parts of the direct interaction of a medical provider and the patient than a real patient.

Of course, patients are volunteering after having given informed consent for a student to either "shadow" a physician or interact with the patient directly. Without these volunteers there would be no medical education for those who have set the profession of medicine as their career. ..Maurice.

 
At Sunday, February 23, 2014 11:25:00 AM, Anonymous Anonymous said...

Dr. Bernstein:

I have a 12 year relationship with my doctor, and I assume that sort of trusting bond is what doctors want to accomplish. I do not have that sort of trusting relationship with a stranger whether pre or med. I can't even imagine how that intimate bond could stay intact with an unknown thrown into the room.It's almost as if the doctor would be denying the worth of that bond, and that the value of any trust built over the years did not have much meaning.
After all " Here's a stranger. Confide in them as you would in me" shows no respect for the years of privacy and respect one thought they had with their provider.

Maybe I am wrong...and providers reject that type of earned personal trust.

Suzy

 
At Monday, February 24, 2014 7:03:00 PM, Blogger Maurice Bernstein, M.D. said...

And that trust with your physician, which doctors recognize is essential for a working relationship, will depend on how your doctor handles the episode with the student and how that doctor deals with your own decision regarding the student's presence. ..Maurice.

 
At Friday, February 28, 2014 5:38:00 PM, Anonymous Anonymous said...

It is absolutely harmful in the absence of true prior informed consent. Its obvious that medical "professionals" (sarcasm intended) do not subscribe to any common basic medical ethics as evidence by this practice and others (pelvic and prostate exams on anesthetized patients by "students"). Patients do have the ethical and legal right to choose who and to what degree a provider (physician, PA, NP, nurse, medical assistant, student, or chaperon) participates in his or her healthcare, even in a teaching hospital. We are after all the patient and customer actually paying for a service. I insist providers participating in my healthcare introduce themselves, cite their professional qualifications, and justify their presence by clearly explaining their role and how I benefit. If unconvinced, I politely but firmly simply say no!

Ed

 
At Friday, February 28, 2014 9:40:00 PM, Blogger Maurice Bernstein, M.D. said...

Ed, what you "insist", I personally and as a physician professionally and as a medical school teacher completely agree. ..Maurice.

 
At Sunday, March 02, 2014 7:17:00 AM, Anonymous Anonymous said...

Dr Bernstein, that's clearly evident by your support and dedication to these issues and this blog! Thank You.

Ed

 
At Sunday, March 02, 2014 9:58:00 AM, Blogger Maurice Bernstein, M.D. said...

As I have already noted in my introduction to this thread, what I am most concerned about is the potential to lose history, to avoid essential physical exam and to alter therapeutic communication with the patient when there is shadowing of physicians by college undergraduate students who have not yet become medical students..and this despite consent to shadowing by the patient.

This may be due to the fact that that a "non-medical professional" student will always be a "stranger" in the doctor-patient relationship. With regard to patient history, it may be hard enough for a patient to tell, even their trusted doctor, some sensitive history, but it would be even more difficult, perhaps unacceptable, to tell that history to two persons. And, a physician who may be aware of potential sensitivity, may avoid asking a question and with time limitations not offer the question to the patient when the student is out of the room. With regard to the physical examination, the physician, aware of patient modesty issues, may alter the examination procedure to protect the patient's modesty concerns with the stranger in the room. Sensitive discussions with the patient about their illness and course may be altered again because of the student's presence.
Finally, the non-medical student, unsophisticated in medical terminology or practices may interrupt what could be a smooth doctor-patient relationship with the students own questions and comments.

Of course, a medical student shadowing could give rise to what I have described but there would be a difference in the tutorial experience of the doctor, the already medical knowledge and sophistication of the student which would make the shadowing much less a handicap for the patient. ..Maurice.

 
At Sunday, March 02, 2014 8:18:00 PM, Anonymous Anonymous said...

"... shadowing much less a handicap for the patient."

While I can't speak for others, any third party presence, regardless of their role or qualifications, is a insurmountable handicap for all but the most innocuous discussions or examinations. Their presence doesn't benefit me in anyway so I see absolutely no need to enable their education.

Ed

 
At Thursday, May 29, 2014 5:49:00 AM, Anonymous María said...

Seems pretty unethical to me.
And there's no way in which
anyone else but the student
would benefit, and then only
a few ones at that.
That's because only a few
select undergrad students
will be able to get proper
insight into the profession,
so it might very well be a
lose-lose-lose proposition
for everyone involved.

 

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