The ethics of medical job shadowing: Who benefits?

The patient was about to undergo surgery when the surgeon came into the hospital room with “a clan of about six ‘student doctors’.”

It was uncomfortable and embarrassing:

As the young students craned their necks to get better views of my condition, I remember feeling so overwhelmed and self-conscious that I didn’t voice any of the several concerns I had outlined to discuss with my surgeon. I’m ashamed to admit it, but I remained quiet as my surgeon prattled on about what he was going to do.

Now imagine the student doctors are high school or college-aged students who aren’t even in medical school yet but are job-shadowing a physician mentor to learn more about a possible career in medicine.

Does the discomfort level ratchet up even more?

Some intense online discussion erupted recently over the ethics of allowing students to observe patient care as part of the career exploration process.

Job shadowing is a time-honored way for teens and young adults to gain a firsthand look at what medicine is like so they can make informed, realistic choices about pursuing it as their life’s work,  writes Dr. Elizabeth Kitsis, director of bioethics education and assistant professor of medicine at Albert Einstein College of Medicine in New York.

But she admits to feeling uneasy about its impact on patients and on their care.

She wonders: Do patients know the “student” observer in the exam room might actually be a high school student? Are they allowed to ask the student to stay out of the room? What if they don’t want a student present but are too shy or intimidated to say so?

More to the point, does the presence of a high school or college student inhibit the discussion of sensitive medical issues? Maybe the patient won’t bring up worries about having contracted a sexually transmitted infection, or might give less than honest answers about alcohol consumption, Dr. Kitsis writes.

She asks: “Are these concerns outweighed by the benefit derived by premed students from being in the room? I suspect that students would respond in the affirmative. But I am not sure what patients would say.”

To help answer some of these questions, Dr. Kitsis and a colleague turned to the research to conduct a study of their own. What they found was a dearth of information on best practices in medical job shadowing, how to measure the effectiveness of such programs and how to address the ethical and practical considerations.

She and Dr. Michelle Goldsammler concluded that more research is needed, and they suggest the development of guidelines and a code of conduct for premedical students who want to shadow a practicing physician.

Judging from the online conversation, most medical students find it valuable indeed to shadow an experienced physician to gain an understanding of a career they’re seriously considering.

Jimmy Tam Huy Pham, a medical student, shadowed in several different settings before entering medical school. Most patients were OK with having him in the room, although many others declined, he wrote.

“The bottom line is: exposure to any aspects of medicine (and as much of it as possible) is crucial for an individual who is about to spend the next 8-11 years of their life (subsequent to high school) in a profession where repetitive exposure and practice to procedures and patient interaction are keys to learn,” he wrote.

“Patients were always asked whether or not they were happy to have me present and, of course, their wishes always respected,” someone else wrote. “Personally, I feel that shadowing was invaluable in helping me to decide that I do truly want to pursue a career in medicine.”

Several people pointed out that shadowing experience is an unofficial entrance requirement at many medical schools in both the U.S. and the U.K.

Many of the patients who joined the online discussion had a different perspective, though.

“A curious teenager in my exam room? Never,” was one person’s response.

Someone else wrote that she did not want “some kid who has nothing to do with my care tagging along with my doctor.” Nor did she want to be in the position of having to say yes or no to allowing a student in the room, she wrote. “Why should patients have to go through that? It’s not the patient’s responsibility to help young people figure out if they want to be doctors.”

Previous studies have found that a majority of patients are willing to accept the involvement of medical students in their care – and that many in fact find it rewarding to help contribute to a student’s education. But most of these studies concentrated on students who have already entered medical school and are able to bring training and commitment to their encounters with patients. Does it – or should it – make a difference when the student is still in the career exploration phase?

Society holds a stake in the training of future health care professionals. After all, today’s student is tomorrow’s doctor, nurse, physical therapist or physician assistant. But do patients have a moral obligation to participate in this process? And when they do participate, what can be done to help ensure it doesn’t compromise their care or their privacy? It would seem these are questions that need to be examined and satisfactorily answered.

8 thoughts on “The ethics of medical job shadowing: Who benefits?

  1. This is a great topic and one that I have had experience with. If a student wants to shadow a medical professional, the medical professional should ask the patient whether or not they are comfortable allowing the student to shadow while the student waits in another area. If the student is present when the medical professional asks permission from the patient, it puts the patient in an awkward situation and may sway them to allow the student to shadow, even though they are not comfortable with it. Another concern with student shadowing is HIPAA (a patient privacy act); if a student wants to shadow me, they have to complete HIPAA training ahead of time.

    • Those are really good points for how to handle job shadowing – a couple of best practices, in fact.

      I don’t think job shadowing should be a huge issue in patient care, as long as there’s respect, transparency and some basic ground rules for how everyone conducts themselves. It really comes down to the professional mentor’s (or health care organization’s) willingness and ability to handle it appropriately.

  2. I believe there is a sort of moral or at least a social obligation for patients to participate in the student education process. Here’s why: I want a physician who is dedicated to his or her work and who is there to help more than to earn a big paycheck. What happens if a student goes through enough schooling to become a “student doctor” and finds out at that moment that the medical environment is not one he wants to work in? Will he be willing to throw away the thousands of dollars already invested, or will he continue on in order to recoup the investment?
    Granted, there are situations that are sensitive and extremely personal, and for these I would hope a physician being shadowed would have the sense to ask a prospective student to step out of the exam room. I would think that the physician could later give a general overview of the closed-door issue to help educate the student without betraying the patient’s trust. This actually happens all the time in government with personnel issues. While administrators and officials may hold private meetings on sensitive personnel issues, they regularly provide a public summary of the discussion that doesn’t disclose personal information.
    I think that addressing student observers in a medical setting in terms of “do you or don’t you” is too restrictive. There are other measures that can be taken. Do students, especially students who aren’t in medical school yet, have to sign a confidentiality statement to ensure they don’t discuss a patient’s condition with anyone other than the physician? If so, are patients informed of this? Are there policies in place to define student-physician interaction in the exam room? I can see how a patient would feel uncomfortable if his or her physician talked more to the student than to the patient, so maybe we need a standard that physician-student conversation should be done after the visit instead of during. There are other steps that could be taken as well, I’m sure, to help patients feel more comfortable while still allowing hopeful physicians to set up accurate expectations for their career.

  3. It wouldn’t bother me for most things. I don’t especially care if a high school student sees my blood pressure taken or takes a peek at the grody strep in my throat or watches a wart frozen off or anything of that nature.

    I like to help people, and letting somebody watch something like that is a pretty easy way to help out.

    That said? My brother’s in medical school right now, and they practically require you to have some physician-shadowing experience before they will even let you in. He had to do a ton of other stuff too–volunteering and the like–but shadowing was a prerequisite *prior* to getting in.

    And it does give you an idea of what to expect if you go into medicine. And I don’t know what people who don’t have strong connections in their communities do.

  4. I’ve always been asked if it’s okay for the student to be there. Only once did I have to say “no” because I wasn’t comfortable with it. Otherwise, I don’t mind.

  5. I am a non-traditional student trying to get job shadowing experience, and it is hard. The medical school I am most interested in applying for requires job shadowing, and you hear a lot of people telling you to leverage your connections. Most of the current medical students that I have met while touring campuses job shadowed doctors in their family. In addition to academic and financial support, it feels like this is one more piece of the design that acts as a hurdle for capable individuals from lower socio-economic groups. If required, medical schools and medical advisors should develop a program for those without pre-existing connections so that we don’t have to spend a lot of time getting rejections based on who we aren’t related to or don’t know.

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