MEdIC Series | Case of the Patient with a No Learner Policy


No students allowedWelcome to season 3, episode 2 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

This month’s case features a problem that many of us have seen in our day-to-day practice: a patient with a strict no learner policy who refuses to be assessed by anyone other than the attending physician. With much of the care in teaching hospitals delegated through fellows, residents, and medical students at various stages of training, how would you address this problem? Please read the case and join in the discussion below!

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Patient with a No Learner Policy

by Drs. Andrew Petrosoniak (@petrosoniak) and Nikita Joshi (@njoshi8)

John, a first year emergency medicine (EM) resident, walks slowly back the physician charting area in the emergency department. He had just spent 5 minutes attempting to gather a history and perform a physical exam on Mrs. Armstrong, a 73 year old lady with a history of COPD who presented with dyspnea. Except, it didn’t go as planned and now he had to explain to his attending why he couldn’t continue.

The attending physician, Dr. Brown, looks up from his charting at John, “Back already? That was fast!”

John explained, “Well, Mrs. Armstrong wouldn’t let me continue the history and physical when she found out I was only a resident doctor. Everything was great until she saw that my badge said ‘PGY-1 Emergency Medicine’” She got upset and refused to answer any more questions. When I asked her what was wrong, she said told me that she wasn’t a guinea pig and didn’t want student doctors practicing on her because she’s been through enough already. She told me she only wanted to speak with a ‘real’ doctor.”

John continued, “I tried to explain to her that I am a physician with an MD degree and that this is a teaching hospital where junior doctors work closely under the supervision of attending physicians, but she wouldn’t listen”.

“Did you tell her that I would hear the story and come meet her shortly? And that all patients are reviewed and examined by an attending physician?” asked Dr. Brown.  “In fact, I often tell my patients that it’s more comprehensive to do it this way than if I went in there myself since the story gets told twice with a resident and we spend time thinking and discussing her symptoms, the diagnosis, and the management plan”.

“I mentioned all of these things but she said that she’s seen too many student doctors in her day and now all she wants is a real one” said John. “When she started yelling at me to leave, I figured that it was best to come get you”.

“Did you introduce yourself initially as a resident?” asked Dr. Brown.

“No, I just said, I’m Dr. Callaghan and I work with Dr. Brown, who you’ll be meeting shortly”.

Key Questions

  1. How should medical students and residents state their level of training during their introduction to a patient?
  2. What approach should junior physicians or students take when speaking with a patient who does not want to be seen or examined by a “doctor in training”?
  3. What strategies can be used by medical students and residents to help the patient better understand how a teaching hospital works?
  4. How should an attending physician approach situations where the patient refuses to see anyone except an attending physician?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Dr. Michael Gisondi (@MikeGisondi), assisted by his medical education fellows, Dr. Abra Fant (@DrAbracadabra) and Dr. Benjamin Schnapp (@Schnappadap) from Northwestern University Feinberg School of Medicine (@NorthwesternEM). Dr. Gisondi is the EM Residency Program Director, Medical Education Fellowship Director, Director of the Feinberg Academy of Medical Educators, and the Chief Strategy Officer of the ALiEM Chief Resident Incubator. In addition to being Medical Education Fellows at Northwestern, Abra studies Healthcare Quality and Safety while Benjamin has an interest in cognitive decision-making.
  • Dr. Jennifer Tang (@jctangmd) is an Assistant Clinical Professor at McMaster University, a practicing emergency physician at Hamilton Health Sciences, and a regional investigating coroner. She has also completed a Masters in Health Sciences (Bioethics) through the University of Toronto and serves as the Ontario representative of the Canadian Medical Associations’s ethics committee.

On November 6, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of the Patient with a No Learner Policy.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at
Brent Thoma, MD MA
  • This is another great case, and particularly valuable exercise for students getting ready to match and start their residencies next summer. The student in the case did a great job of respectfully communicating with the patient, but it seems the larger issue here is a lack of general public understanding of teaching hospitals, their unique care giving paradigms, and the added value they provide. That is much more than can be communicated by one resident, especially to a reluctant patient. Residents must be sensitive to the fears some patients may voice about wanting the care and attention of a more experienced physicians-especially when we remember the power differential and inherent vulnerability of patients. This case does suggest however that residents also have an opportunity to do some positive education of the patients they treat who are open and receptive to junior doctors. We look forward to your expert responses!

    • Brent Thoma

      Thanks for your reply! I agree, this case highlights some issues that are bigger than a single interaction. I think the understanding of medical residents and their role in our health care systems is quite poor. How do you think this can be best addressed? And by who?? Our questions focus on the learner and the attending, but your comment makes me wonder if there are other people/groups that ought to be involved at addressing this issue at a higher level.

      • There has been some recent media coverage of at least one hospital system that changed policy to have nurses discuss a patient hand-off in the patient’s room. It’s transparent, inclusive, and reduces the risk that some key information is lost. it’s another opportunity for the patient to be involved in planning their care. It seems that this model can’t be adopted whole-cloth for medical residents, however, because the report-out they do with the attending is a teaching moment. If conducted in front of the patient, the substance of this conversation would likely change- moving away from questions about handling patient encounters and suggested but ultimately wrong diagnoses. But it’s clear that increased patient engagement in care and healthcare system accountability are pushing us towards greater inclusion and transparency. Perhaps there will come a day when the resident debrief to the attending can comfortably happen in front of the patient, without degrading the learning opportunity. Would love to learn if some systems are already moving in this direction.

    • Loice Swisher

      I agree that the communication was not disrespectful, however, it does seem to only push the ‘doctor agenda’.

      In having the patient experience myself, I think that want patients (and people in general) want is to be really heard and to feel like they are not alone. I suspect a better understanding can come from intently, nonjudgementally listening to the patients fears, angst and prior experiences- to find out what she has been through rather than telling them again all the great benefits it is to have residents involved in their care. If the patient has been in a teaching hospital, they have already come to the decision on how hollow or true the claims ring for them.

      It could be possible that once seen by the attending that they patient might be open to a resident also being involved in the care. Many patients realize that virtually all orders from an intern need to be approved by an attending- at least initially- so that having an intern actually might feel like a delay in their initial care.

      • Brent Thoma

        Great advice!

        I can see how it might come off as being ‘tone-deaf’ to try to sell a patient on the benefits of learners participating in their care when they’ve had learners and it didn’t seem to work like that. Really listening to the patient would help to determine whether a patient has misconceptions about learners’ roles in the healthcare system or whether there is something else that led to this response.

        Thanks for commenting!


        • Loice Swisher


          For me it does seem ‘tone deaf’ and views all patients as a homogenous, uneducated, medically inexperienced group.

          Obviously there is a huge group of patients who fit into this category. These folks might not have been given the information to know how the hospital works or might have misconceptions likely generated from TV and friends. There has been some work in EM that specifically looks at patients’ perceptions-

          That is not this patient. This patient has had the experience of “too many student doctors in her day” and she had “been through enough”. For me, this is different. She has allowed medical students and residents before. Either something has happened in a prior experience that soured her or there is something more going on this time which has caused this reaction.

          To me the issues might ultimately resolve with different approaches. The first group might benefit from education/information. The latter is one where listening is more likely to heal the divide.

          As one falling into the latter group, being “educated” on the system feels paternalistic, condescending and dismissive. I’m would guess that Mrs. Armstrong has had more COPD exacerbations herself than an the average PGY-1 has seen. She probably also has seen more students and residents in her medical experience than are in the program that this PGY-1 is in. To be ‘taught’ what one should expect as a patient would completely turn me off. On the other hand, coming to me as a person might have changed the response.

          In addition, I think the attending’s response is tone deaf- “In fact, I often tell my patients that it’s more comprehensive to do it this way than if I went in there myself since the story gets told twice with a resident and we spend time thinking and discussing her symptoms, the diagnosis, and the management plan”.

          Having to tell the story twice (actually more like 4 times with nurse and triage) is exactly one of the things that tick patients off.

          The discussion rarely is visible and palpable to the patient as it is uncommon to happen at the bedside. It is really hard to comprehend how a trainee will add to the attending’s management plan and not just delay care by discussion the disease rather putting in orders to get care started. If you want to list benefits it got to be better than ‘you get to tell your story twice and we get the opportunity to talk about you without you being present’.

          Perhaps if one wants patients to feel like there is a benefit then they should have more resident-attending discussions and presentations at the bedside.


  • Tamara McColl

    Great case!

    I think it’s natural for patients/families to question the skill level of their physician. They’re presenting to hospital because something is wrong – they’re scared and vulnerable and want to make sure that nothing is overlooked. Particularly now, in the age of technology where patients are often their own “wiki-doctors” – they frequently come in worried about the worst possible scenario – that they have some rare disease, or cancer, or that they’re dying… Now imagine having these thoughts and then being introduced to a medical student or junior resident who will be overseeing your care without having a solid grasp of what that actually means.

    Most patients have very little understanding of how the hierarchy of the hospital works and don’t realize that being seen by a medical student/junior resident will often mean that their case will be reviewed again by a senior resident and by an attending staff as well. This is actually a huge bonus for them! Medicine is complex and details can be missed even by a seasoned physician – Two (or three) heads are better than one!

    Having a learner involved in their care can also result in an expedited work-up and management plan since the coordination of care is more efficient with multiple physicians on board. Additionally, residents (in general) tend to be more up to date with current literature and FOAM material and can offer more innovative diagnostic/treatment options in certain cases.

    Bottom line, medical students and residents are an integral part of the healthcare team and are essential in delivering the highest level of quality patient care. Without them, a tertiary care academic centre would not function. Period. So it’s essential that our patients are well versed with how the hospital functions and what it means to have a learner as their primary contact within the system. The solution could be as simple as having a verbal or written explanation provided at triage.

    In terms of introductions, honesty is certainly the best method. Patients should know who you are and what level of training you have achieved. And this should be done when you walk into the room and introduce yourself – something John did not do. His patient had to learn he was an R1 resident by looking at his badge halfway through the history. This omission of information was likely a factor in the patient’s refusal to be seen by a learner.

    I personally have never had a patient refuse to be seen by me, but I did have a case where a patient refused to be cared for by my medical student because he wanted a “real doctor”. In this situation, I went into the room with the student, explained that we were at a teaching hospital and I stayed in the room while the student proceeded to take a history and physical exam. Somehow just having me in the room seemed to deescalate the situation since the patient now felt like someone more senior was involved in his case and not just a student. Lack of understanding/knowledge of our system was certainly the issue since he would have received the same level of care either way.

    • Brent Thoma


      Thanks for the great reply.

      I think you hit on a number of key issues: lack of patient understanding of the roles of junior physicians, the need for and potential benefits of learner involvement in care, and the importance of an honest introduction. When you outlined the benefits it made me think of how we weigh risks/benefits when getting a patient’s consent for a procedure. I’d agree that, generally, the benefits far outweigh the risks!

      I also like the tip of having someone more senior step in to deescalate and support the learner, although on some services that might not always be feasible. Any other strategies for helping to explain a learner’s role in health care?


      • Loice Swisher

        I really question if it is the patient lack of understanding of the junior physician’s role. My sense is that it is the experience patient (either as the the actual patient or as a care-giver) who asks for the attending. They know the road and sometime they just want to get through it.

        If one has actually had the experience of “the system” having to tell the story to the triage nurse and then many of the same questions to the primary nurse and then again to the student and then to the resident and then to the attending, well, it can honestly feel quite frustrating- almost uncaring of one’s time/concerns. It is more like just going through another one and grinding out the meat. And sometimes, no it isn’t doesn’t seem worth it if you as a patient have done this 10 or 20 times before ( including clinic). From the patient’s perspective, sometimes one just doesn’t have the energy as perhaps a daughter was just dx with cancer or a husband died or you have an overwhelmingly feeling that this time is different and it is cancer.

        Of course there are benefits to the learner but the patient might have very different views on what is a benefit to them. I feel it might be belittling to say the patient’s lack understanding of the medical system when many have had multitudinous interactions in the medical system. What I find is that few medical students, residents and even young attending have had any long term experience with being a chronic patient. In fact, it is the docs that don’t understand how the medical system works for a patient.


        • Brent Thoma


          Once again, I very much appreciate the patient-perspective that you are providing. Thanks for your insightful comments.

          How do you think medical educators can help learners to better understand the patient experience?


  • Casey Glass

    Great case, fortunately it seems to be something that happens rather infrequently, at least where I work. I think it is clear that students and residents clearly communicate their training role and communicate early that the attending physician will also be evaluating the patient in a timely manner.

    I’m going to take the last question and then go back to the others. When this would happen to me as a resident or when it happens to my residents it can make you feel undervalued and under appreciated and that is certainly understandable. It is often tempting to push back with thoughts like “Hey, didn’t you know this was a teaching hospital!” It is important to remember that the right of the patient to determine their own care course is a very high priority and that includes determining which doctors are taking care of them. Although there is the illusion of choice (why did you come here if you didn’t want to see residents!?) when it comes to emergency care many patients don’t have a choice – the ambulance takes them where it will take them, or because of geography or location of specialists they simply must see you. There isn’t a practical option to avoid a teaching hospital.

    Sometimes these patients have had bad experiences with trainees. It is possible even in a teaching institution that their other care is on a “Chairman’s Service” where they see only attending physicians. Don’t make assumptions about their motivations – if they don’t want to see trainees there may be good reasons for that.

    So when a resident tells me a patient has played the “no trainees” card I smile and go and take care of the patient. We might have a talk about why they prefer not to have residents but overall I just take care of their ED visit. Maybe this makes space in their world for a good interaction with trainees in the future and overall it’s not a big deal. It happens so infrequently that it does not affect learning experiences for trainees (except how to deal with difficult patients). It certainly is no big affect on my day and patient autonomy is respected.

    In my opinion the *wrong* thing to do would be to force a resident on that patient. There is no way to have a constructive patient-physician relationship at that point and you’re going to be stuck just gritting your teeth and getting through it.

    In terms of Q2 and Q3 – sometimes patients are in for the first time and they just don’t get how it works (I mean it took me years to really understand how it works). Trainees should explain that they are part of a team that will be caring for the patient just like the nurses and other staff, and that the supervising physician will be able to answer any other questions when she sees the patient as well. Smile, answer questions, and keep smiling. Things go sour when you wear your frustration on your face.

    Big picture – patients should be able to determine their care to the extent possible. In the ED this shouldn’t amount to more than a little injured pride. Shake it off–there’s an abdominal pain in bed 9 that needs to be seen.

    -Casey Glass, MD

    • Loice Swisher

      I am so glad that you approached this from the patient’s perspective. I totally agree that as the attending one should respect the patient’s wishes and then go take care of them. I also agree there is no negative impact on the trainee in medical education and might build some experience in dealing with such situations in a positive manner.

      I have had the opportunity to have a second medical education sitting on the other side of the stethoscope when my then 5 year-old daughter was diagnosed with a malignant brain tumor and subsequently entirely neurologically devastated with resection. She came out of surgery blind, mute, incontinent and completely unable to do any voluntary movements but able to think and hear like a normal pre-schooler (severe cerebellar mutism/posterior fossa syndrome from which over the years she has recovered nicely).

      I had no choice but to take her to a teaching hospital- that was the only place she could get treatment. Our first two years of treatment she spent 400 days either inpatient or outpatient in the hospital. Obviously, I know the system and am a medical educator. Usually it was fine for whoever to come by and do whatever. In fact, often times I loved educating healthcare practitioners- especially on poorly known late effects of childhood cancer treatment.

      There were times though that I was the scared mom carrying my somnolent child with the disconjugate gaze into the ED. What I needed was a shunt series, a CT and a neurosurgical resident. I was terrified of a bleed or a stroke from her fragile previously irradiated cranial vessels or recurrence or maybe it would be “just a shunt failure” and I would have to consent to the straw being removed from the her head hopefully not being fibrosed and causing another neurologic hit. It was not the time to go through a detailed student or intern H&P for me and I wasn’t going to delay may daughter’s care for someone else’s learning possibly allowing her to herniate in the meanwhile.

      Yeah, you can say I am an ER doc and have “special knowledge” but I can promise you virtually ever medulloblastoma parent who has been in this for a little while knows the path- that any one of the branches is possible and who can help us know which dreaded alternative we are taking.

      From my patient advocate side, I wonder if anyone ever asked her if she felt like she was “treated like a guinea pig” or to explain what “she has been through”. My guess is not. It takes too much time and people would rather try to convince them and twist their arm to get what “they” (the doctors and nurses) want done to make their life smoother. If one did, more likely than not it is understandable that they don’t want to go through something again. The PTSD of being a patient.

      I think residents would agree to getting the attending but worry how the attending would respond. Would it would negatively impact the resident’s eval. Worse would it negatively impact the patient- the punitive ‘fine then they can wait’ response.

      It can be hard being a patient. We shouldn’t make it harder.

      -Loice Swisher, MD

      • Brent Thoma

        Thank you for sharing your story with us. It really humanizes the discussion and underscores that we and our families will all be patients some day.

  • S Luckett G

    I have a script for introducing myself that goes something like, ‘Hi, I’m Dr. Luckett-Gatopoulos. I’m one of the resident doctors working here.’ As a medical student, I would say, ‘Hi, I’m Luckett. I’m one of the medical students working here. My job today is to find out more about why you’re here, examine you, and then speak with Dr. Brown, the attending doctor about you. Together, we’ll come up with a plan.’ I’ve rarely come up against any resistance, and patients seem to understand who I am and what my job is.

    Occasionally, I’ve had a patient ask me whether I am the doctor, or whether I am ‘a real doctor’, and I deal with that essentially as John described to Dr. Brown with a bit of a twist: I explain that I am finished medical school and doing specialty training in emergency medicine. I feel that emphasising that I already have an MD and am training as a specialist puts most patients at ease. In the rare instance where this hasn’t worked, I’ve explained, exactly as John did, how things work at a teaching hospital. It can be hard to stay coolheaded during these interactions, but if I can, I usually get good traction. Some patients are still not willing, and I explain to those patients that that is okay, but that the wait will likely be longer to see the staff doctor (which is true). I’ve had maybe one or two patients refuse to see me at that point, and while I wouldn’t go so far as to say that that is their prerogative (in Canada, you can’t pick and choose your options!), there is no way I can force them to see me, and I wouldn’t want to if there is another physician available who can build a good rapport where i cannot.

    It’s understandable that patients may feel worried, scared, or used if they are being examined by individuals in training. Indeed, we often couch our approaches to them in terms of helping with our learning, and when we flip the script and say ‘actually, it’s good for you’, it can seem a bit disingenuous. One of the advantages of being a trainee is having the time to explore these issues if the patient is willing. Sometimes just asking a patient what worries them about seeing a trainee is enough to both earn their trust and address their concerns. There are a lot of misconceptions about trainees as unsupervised and ignorant cowboys that come from popular media – I would be scared to be treated by the Grey’s Anatomy residents! The odds are really stacked agains us when we are in these situations, particularly if the patient has already had an unpleasant or unsafe interaction with a trainee.

    • Loice Swisher

      I love your reply-especially because it encompasses the feelings of a trainee (hard to remain cool-headed) as well as some specific scripting. Asking what worries the patient about trainees respects them and gives them a chance to express/vent their feelings. And if one can meet them where they are- even joining with them- it is even better (no Grey’s Anatomy residents here).

      Maybe it is easier to remain cool-headed to remember it isn’t about you. Usually the patient has never met you before. It truly is them- their perceptions, fears, angst, experience. I find things go wrong when you make it about you- the I have to make sure they understand, I have to convince them, I will look bad.

      I’m sorry that the attending seemed to make this resident feel wrong and that it could have been about him not introducing himself in a more transparent way. Although more a transparent introduction like you do is way better, I doubt that would have helped as patients don’t always get the different levels of training (but they do know the difference between a 1 and 3).

      I’d love to see the next part of the story on what the attending did next- that is the part that will make the difference on the resident education.


  • mattycoze

    Hi Brent,

    As a medical student, this is something that gets me particularly anxious when thinking about working on the wards (in years 3 and 4)… We are frequently told that it’s important to be upfront in our introductions;

    “Hello Mrs Norris, my name is Matthew, I’m a 3rd year medical student at the University of ______”… before promptly explaining what the purpose of the interview is. I agree that this should be the case – in my mind there’s nothing worse than being “found out” by the patient that we’re an impostor (so to speak!).

    In cases where patients have a ‘no-learner policy’, it would seem worthwhile to try and ascertain more about what the patient is anxious or weary about. So here are my ideas for tactfully improving rapport;

    – patients may like to hear that we’re here to advocate for their health and convey important details that the consultant/senior physician may want to know about.
    – patients may worry that their care is not being taken seriously; so showing empathy is important by showing concern for situations…
    – assurances of confidentiality of medical information is important
    – perhaps ask if they’ve had any negative experiences talking to junior staff, and if they would be open to talking about that

    It might interest students to know that ~30% of patients in Australian public hospitals are open playing an active role in our education when we approach them. We also stand to learn a lot from the remaining 70%! (I certainly do anyway).

    I am sure what I have to say on this may appear naive and terribly idealistic as I have no real experience dealing with resistant patients. I hope it gives some insight into what I expect to be the main challenges.

    Cheers M@

    • Brent Thoma


      Thanks for that great reply. Honestly, I think the fact that you’re concerned about this will result in you having few problems with this sort of thing.

      I’d be interested to know where your ~30% number came from and what an “active role” means. Is that willing to actively help? Or just be seen by a learner? I feel like the proportion that are willing to be seen be a learner is a lot higher!

      Your approach of being upfront with your role, listening to their concerns, and respecting their decision seems to be consistent with the rest of the feedback. Appreciate your thoughts.


  • Samantha Lam

    So far as a student, I have not encountered this scenario too often, but when I have, at the least I’m usually able to elicit the reasoning and convey it to my preceptor, then see the patient together.
    I usually start my introductions with “My name is [ ] , a student working with Dr. [ ] in the [ dept]. We will be looking after your care today”. I think it helps with the rapport when students express taking ownership.
    When patients initially ask to be seen by the attending first, I make sure that I take the time to listen to their reasons. I’m conscious to not interrupt and give them time and space. Often, this conversation becomes a segue for the reasons for their visit and the actual interview itself.
    Granted, I’m still very early in my career, and I am sure that when I encounter very complex and chronic cases that will pose another set of challenges. However, if I am unable to interview, I make sure that I am present when the attending does.

  • Dr. Howie Mell

    So, I’ll take a slightly different, and perhaps unpopular view. Imagine that your family member has a known, difficult to manage condition. Say they are known to be a difficult intubation with true anaphylaxis to sux. Or are s/p multiple spine surgeries and need a spinal. Are you letting the PGY-1 or PGY-2 anesthesia resident intubate them for surgery? Or do the spinal?

    While not as severe as I set up above, I have a family member who is prone to anesthesia complications. I have “excused” learners after discussions with them revealed they discounted previous team’s difficulties. While we did allow them to manage the initial portions of the case, both my family and I quickly lost confidence in their planned approach and asked for an attending.