What Should Medical Students Do If A Patient Refuses To Be Examined by Them in a Teaching Hospital?

The Case of the Patient with a No Learner Policy Case



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”.

Involving Learners is a Social Contract

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. [1] 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 [2]. An earlier study by Hicks et al [3] 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.

Conclusion

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.

References

1.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

2. Picard, A. Time to end pelvic exams done without consent. 2010 January 28. The Globe and Mail. Accessed: October 14, 2015.

3. 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

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