Last week, we launched the second case of the ALiEM MEdIC series third season. The Case of the Patient with a No Learner Policy hit close to home for some of our regular contributors and many new ones. We are proud to present the Curated Community Commentary of the case discussion along with the opinion of our 2 experts. Thank-you again to all our experts and participants for contributing again this week to the MEdIC series.
As always, we post the expert responses and a curated commentary derived from the community responses one week after the case was published (also available in a PDF version below!). This month one of our expert’s took a collaborative approach to his response, recruiting his education fellows to serve as co-authors. The experts for this case were:
- Dr. Jennifer Tang (@jctangmd) is a Canadian emergency physician who works at Hamilton Health Sciences. She is a Clinical Scholar affiliated with McMaster University. Jennifer completed her Emergency Medicine Royal College (FRCPC) training at Queen’s University (Kingston, ON) and her Masters in Health Sciences (Bioethics) through the Joint Centre for Bioethics at the University of Toronto. She completed a practicum in clinical ethics at Trillium Health Partners and, in the past she served on the Queens Health Sciences Research Ethics Board. She enjoys teaching and developing ethics and professionalism curriculum for medical students and residents.
- Drs. Michael Gisondi (@MikeGisondi), Abra Fant (@DrAbracadabra), and Benjamin Schnapp (@Schnappadap) – Drs. Abra Fant and Benjamin Schnapp are Medical Education Fellows in the Department of Emergency Medicine at Northwestern University Feinberg School of Medicine. In addition to medical education, Abra studies Healthcare Quality & Safety and Benjamin is interested in Cognitive Decision-Making. Dr. Michael Gisondi is the EM Residency Program Director and Medical Education Fellowship Director at Northwestern University as well as the Director of the Feinberg Academy of Medical Educators, the Chief Strategy Officer of ALiEM Chief Resident Incubator, and the co-host of ALiEM EM Match Advice.
For many patients and families, a visit to the ED is the scariest day of their lives. It is understandable that they want to receive the best care possible. Having a learner walk into the room rather than the attending physician may make the patient feel as if their concerns are not being taken seriously. Television dramas like Scrubs, ER, and Gray’s Anatomy may be the only exposure that the general public has had to medical learners. While it may be entertaining, television doesn’t always reflect the training and supervision that learners receive in teaching hospitals.
Medical learners should be transparent about their level of training when introducing themselves. They should wear their identification badges visibly and reassure the patient that their case will be reviewed with the supervising physician. With so many terms in the learner hierarchy (medical students, interns, residents, fellows…) saying that you’re a resident may not mean anything to a patient. I suggest that residents introduce themselves by saying, “Hi Mrs. Armstrong, I’m Dr. Callaghan and I’m a resident doctor training to be a specialist”.
Dealing with Rejection
Learners should not take it personally when a patient refuses to have them involved in their care. In response, they should remain calm and professional and not force the issue. Defensiveness will likely escalate the situation and increase the patient’s antipathy towards learners. It may be reasonable for the learner to inquire about why the patient prefers to be seen by the attending. However, if any hostility is perceived, the learner should politely excuse themselves and get their attending physician.
The Patient’s Perspective
There are many reasons why Mrs Armstrong may not want learners involved in her care including fear, prior negative experiences, or cultural considerations. Certain groups fear the medical establishment because of historical situations where respect for their personhood was superseded by their role as teaching subjects. In 2010, a study by Wainberg et al.  examined female patients’ expectations of gynaecological operating room personnel. It found that only 19% of patients were aware that a medical student might do a pelvic exam in the operating room while they were under anesthesia. 72% felt that it would be important to obtain consent for this procedure. This article ignited a debate about informed consent and the role of learners . An earlier study by Hicks et al  detailed other unethical behaviour that medical students witnessed or were pressured to participate in. However, medical education has come a long way since then and it is now widely accepted that the involvement of trainees in patient care without consent is unethical.
When I was a medical student one of my attendings told a patient that they had “no choice” regarding the involvement of learners because “this is a teaching hospital”. It is important to emphasize that even in teaching hospitals patients have the right to reasonable accommodations in choosing their practitioner. However, the attending should explain that teaching hospitals rely on learner involvement and that some procedures and care will not be safe or possible without them. Accommodations that adversely affect the care of other patients should not be considered reasonable.
Addressing the Issue with the Patient
Attending physicians should communicate in a gentle and empathetic manner with patients who have refused learner involvement. Providing reassurance that they will be cared for regardless of their preferences can be followed by an exploration of the reasons why the patient refused. Clarifying misconceptions and explaining graded responsibility may ease their opposition. Many patients express misgivings at being the “first” person a learner performs a procedure on, not realizing that they have access to high fidelity simulators, animal/cadaver models, and/or standardized patients. When I see a patient that requires a procedure that a learner would benefit from performing, I ask the patient for their permission without the learner in the room to minimize feelings of coercion. Patients appreciate being and it is important to thank those who allow learners for their contribution to medical education.
Beyond the patients we see in the ED, education of the public is important to ensure that patients understand the role of learners in our medical system. This can occur in many ways: media campaigns can explain residents’ roles, television shows can use medical consultants to ensure the accurate portrayal of medical trainees, and medical learners can get involved in community outreach events. The more the public interacts with accurate material about medical learners the better understanding that they will have of their roles.
Learner involvement in patient care is an important part of a social contract. If learners do not gain adequate experience during their training, it may negatively impact the care of their future patients. At the same time, we must respect patient autonomy and try to find a compromise between patient rights and the greater good. Being involved with patient care is a privilege, not a right.
- Wainberg S, Wrigley H, Fair J, Ross S. Teaching pelvic examinations under anaesthesia: what do women think? J Obstet Gynaecol Can. 2010; 32(1): 49-53. PMID: 20370981
- Picard, A. Time to end pelvic exams done without consent. 2010 January 28. The Globe and Mail. Accessed: October 14, 2015.
- Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ. 2001; 322(7288): 709-10. PMID: 11264209
Balancing Patient and Trainee Expectations
This case wonderfully illustrates a simple conflict of expectations. Physicians expect that patients who seek care at teaching hospitals will agree to treatment by a team of providers, including some providers-in-training. Patients expect the very best care and, unfortunately, some believe that involvement by trainees leads to suboptimal treatment . Patients commonly refuse care by students in the setting of sensitive exams or procedures  and a small minority prefer not to have inexperienced residents perform necessary procedures . While we take for granted that patients at academic medical centers understand the hierarchical roles that underpin medical education, research has shown that this is not the case .
The Ethics of the Matter
It is possible that Mrs. Armstrong does not fully understand the roles of the providers who are caring for her. Consistent with the bioethical principle of autonomy and the ethics code of the American Medical Association , we must provide maximum disclosure of provider roles and comply with patient preferences to the greatest extent possible. Patients should participate in medical education strictly because of altruism and should not be tricked or forced to receive care from providers they are uncomfortable with [6,7,8]. In cases like this, we should attempt to transfer care to the preferred provider or arrange reasonable accommodations to respect the patient’s preferences. However, there is no ethical obligation of physicians to honor unreasonable patient requests; for example, a patient cannot demand a male physician when only female physicians are available.
Improving the Encounter
Even if Mrs. Armstrong’s request is reasonable, there may be options that allow the resident physician to participate in her care without violating her autonomy. As the supervising physician, Dr. Brown should directly address Mrs. Armstrong’s concerns. There is likely an underlying reason for her request and, if Dr. Brown can understand her motivations, they may be able to reach a compromise. Dr. Brown should begin the encounter by clarifying roles and reassuring the patient that the supervising physician is in charge of all treatment decisions. With patients like Mrs. Armstrong, an early appearance by the attending (possibly along with the medical team) could provide reassurance that learners will not delay or compromise care. This approach also serves to emphasize the team-based nature of care at an academic centre with each team member playing a valuable and unique role.
Given the confusion surrounding trainee roles and titles, John should consider being more explicit with his introductions. He is certainly within his rights to introduce himself as, “Dr. Callaghan” – in fact, introducing himself as a “Doctor” is professional and more likely to elicit a relationship of respect with the patient. However, he should also provide a description of his role within the medical team and an acknowledgement of the supervision provided by his attending. Both John and Dr. Brown may benefit from communications training that simulates difficult situations like this one. One study showed that participation in a simulation-based program increased preceptor confidence in addressing patients who refuse learners’ participation in their care .
The critical lesson for both John and Dr. Brown is that clear and explicit communication is key to any successful patient interaction. While John’s education is important, the priority for every encounter is patient care. Open and honest communication with patients allows students to participate in patient care ethically as both a provider and learner.
- Birkinshaw R, O’Donnell J, Sabir J, Green S. Patients’ attitudes to medical students in the accident and emergency department. Eur J Emerg Med. 1999; 6(2): 109-10. PMID: 10461552
- Ryder N, Ivens D, Sabin C. The attitude of patients towards medical students in a sexual health clinic. Sex Transm Infect. 2005; 81(5): 437-9. PMID: 16199748
- Santen SA, Hemphill RR, McDonald MF, Jo CO. Patients’ willingness to allow residents to learn to practice medical procedures. Acad Med. 2004; 79(2): 144-7. PMID: 14744715
- Santen SA, Hemphill RR, Prough EE, Perlowski AA. Do patients understand their physician’s level of training? a survey of emergency department patients. Acad Med. 2004; 79(2): 139-43. PMID: 14744714
- Opinion 8.088 – Resident physicians’ involvement in patient care. AMA Code of Medical Ethics. Accessed 10/15/15.
- Waterbury JT Refuting patients’ obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students. Med Educ. 2001; 35(3): 286-94. PMID: 11260453
- Lowe M, Kerridge I, McPhee J, Hart C. Do patients have an obligation to participate in student teaching? Med Educ. 2008; 42(3): 237-41. PMID: 18221270
- Gilbert HC, Rich BA, Fine P. Quality of care, teaching responsibilities, and patients’ preferences. Pain Med. 2004; 5(2): 206-11. PMID: 15209976
- Tang TS, Skye EP, Steiger JA. Increasing patient acceptance of medical student participation: using interactive theatre for faculty development. Teach Learn Med. 2009; 21(3): 195-200. PMID: 20183338
Over the last week the ALiEM community has had a solid discussion on the issues raised in this case. The following commentary was curated from the first 19 comments made on the original blog post. Following a detailed review, I believe the discussion can be summarized by outlining five main themes.
1. Listen to the patient
The importance of listening to the patient was reiterated time and time again. There are dozens of reasons why a patient might not want to be seem by a learner. Perhaps they have had bad experiences in the past, they might have misconceptions of the role of trainees in medicine, they could feel like a ‘guinea pig,’ they might have a rare or misunderstood condition, or maybe they are just sick of telling their story over and over again . Regardless, we will not be able to figure this out unless we listen to them and working to understand why a patient feels the way that they do should be our first step in this situation.
2. Be honest
Several comments focused on the best way to introduce oneself to patients. The consistency between all of the examples was that they were extremely honest about the level of training of the learner and the role that they would play in the patient’s care.
3. Clarify any misconceptions
This is the second point on the list for a very important reason: patients might not have any misconceptions. Assuming that they do before hearing their rationale is likely to seem paternalistic and worsen rather than improve the relationship that the patient has with learners. In the event that listening to a patient does identify misconceptions about the role that learners play within the healthcare system as it often will , it may be appropriate to tactfully address their concerns. This strategy will not be appropriate in many interactions and learners will need to tread carefully to ensure that the conversation is building rapport rather than becoming acrimonious.
4. Remember that the patient is the vulnerable one
Patients presenting to the emergency department are frequently in a very vulnerable position. The common adage that the patient “shouldn’t have come to a teaching hospital if they didn’t want to be seen by learners” may be frequently untrue. The hospital that a patient presents to is much more likely to be related to proximity and/or the availability of the services that they need than it is related to the presence or absence of learners. This is especially true for patients with emergent or rare illnesses.
5. And that it’s not about you
It can be tempting for learners feel unappreciated when hearing that a patient does not want to be seen by them after all of the resources, energy, and time that they have put into learning to take care of patients in the best way possible. As it is unlikely that they have ever met you before, it is not personal from their perspective so learners should not respond to it like it is. It’s important to remember that, to a large degree, the patient has the right to determine who will take care of them and a good therapeutic relationship must be built upon mutual respect.
- Malcolm CE, Wong KK, Elwood-Martin R. Patients’ perceptions and experiences of family medicine residents in the office. Can Fam Physician. 2008; 54(4): 570-1, 571.e1-6. PMID: 18411387
- Hemphill RR, Santen SA, Rountree CB, Szmit AR. Patients’ understanding of the roles of interns, residents, and attending physicians in the emergency department. Acad Emerg Med. 1999; 6(4): 339-44. PMID: 10230987
List of Participants
- Loice Swisher
- Tamara McColl
- Casey Glass
- S Luckett-Gatopolous
- Matty Coze
- Samantha Lam
- Howie Mell
- Careers in Medicine
MEdIC Series Case and Responses for Download
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at CanadiEM.org