Appendix 1 - Informed Consent

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


What's Up, Doc?

From a book called Residents: The Perils and Promise of Educating Young Doctors: "Trainees are almost never properly identified as interns, residents, and medical students. A common deceit in teaching hospitals is allowing patients to assume that medical school students are MD's - calling them 'doctor,' though they may be many years from earning their degree."[1] It may even be illegal for interns to use the title "doctor" because they are not yet fully licensed physicians.[2]

A 1995 survey of 149 medical students found that all of them - 100 percent - had been introduced as "doctor" by hospital staff.[3] This not only violates federal and professional guidelines,[4] it's explicitly illegal in Massachusetts.[5] Although most students felt uncomfortable with the deception, less than half corrected the information to the patients.

The Joint Committee on the Accreditation of Hospitals proclaims that, "The patient has a right to know the identity and professional status of the individuals providing service to him.... Participation by patients in clinical training programs... should be voluntary."[6] Letters were sent to all the CEOs of the primary teaching hospitals in the country to check compliance with this guideline. According to this CEO survey, only about a third of major teaching hospitals specifically inform patients about medical student involvement.[7]

Trust Me, I'm a Doctor

The faculty are responsible for most of this deceit. When students are on their own, most introduce themselves as medical students (even though less than ten percent actually explain what that means).[8] While their behavior is more respectful than that of their teachers, their attitudes and knowledge leave much to be desired. In a national survey of 1500 medical students, even of the students that identified themselves truthfully, half didn't think hospitals should have to obtain consent for student involvement in pelvic exams, a quarter believed that, "All patients were 'teaching patients'" and 40% didn't think patients have the right to reject student participation in all aspects of their care.[9],[10],[11]

Researchers set out to survey all of the medical school deans of the country about this issue. According to the deans themselves, a few medical schools actually instruct their students to introduce themselves as "Doctor."[12] Half the schools had no policy at all.[13] Evidently suspicious that the half with policies weren't enforcing them, researchers surveyed all the corresponding chairpersons of the clinical departments to double check. They found that indeed many of the policies were not being implemented by the department chairpersons at the same schools.[14]

From an article in Academic Medicine:

Contrary to the expectations of the patients and the evocations of the professional [medical] community, the first mission of teaching hospitals is conceived by many doctors to be medical education rather than patient care. This belief is shared by many medical students, interns and residents, and it fosters a convenient but anachronistic instrumentalism and paternalism. The comments of one resident explaining his work during an emergency surgery illustrate the mentality: 'I'll practice on this guy tonight so that next year when some ninth grade girl gets shot like this I'll know how to do it. This may be the guy's only contribution to society....' The underlying postulate is that patients should (and will) accept student participation as an implicit 'price' for the exceptional care received in academic institutions.[15]

Appealing to the educational value of asking permission, one author argues, "A student can gain valuable experience by affording patients their rights." A medical school dean rebuts in an editorial entitled "To Inform or Not to Inform Patients About Students":

Many patients are incapable of understanding the complex, subtle and often intuitive methods by which physicians make decisions; may lack the intelligence or education, or they may be too emotionally distraught.... Informed consent, therefore, may at times to undesirable and/or undesired.[16]

Entitling the Student Doctor[17]

From an editorial in the Journal Of General Internal Medicine:

As both status and security markers, name tags are worn in a variety of settings... but nowhere are they so important as in healthcare, where people - our patients - are at their most vulnerable: ill, afraid, in pain, partially clothed (or not at all), often separated from their friends and family, and implicitly obligated to follow the instructions of the professional staff.[18]

Terms used around the country [on medical student ID name tags] include 'student physician,' 'student doctor,' 'MD student,' and, my personal favorite, the letters 'MD' in large type followed, in much smaller type, by 'Prog.' (The authors do not state the meaning of this abbreviation - I assume it means 'Program.')[19]

Tufts is in the 18% minority of schools that has only the student's name and university affiliation on the name tag distributed to third year medical students on their clinical rotations. Tufts does not identify us as medical students.

To find out if the different name tag suffixes made any difference to patients, four student descriptions were tested. Patients were asked to guess the level of experience of each one of the four student descriptors 'medical student,' 'student physician,' 'student doctor,' and 'MD student.' Not surprisingly, patients thought 'medical student' indicated less experience than the other three (p<.0001)*. The authors conclude the obvious, "To emphasize students' lack of experience to patients and make it more difficult for physicians or medical students to verbally introduce students as 'doctors' or 'physicians,' we think name tags ought to refer to students as 'medical students.'"[20]

* A "p-value" is a measure of how likely a finding may have just been due to chance. A value as low as .0001 makes the finding highly statistically significant (the cut-off for significance is anything less than .05 by convention).

A Nice Word for Lie

From the editorial that accompanied the name tag study in the Journal of General Internal Medicine:

Faced with the results of this study, we can no longer pretend that all the various terms used on name tags mean the same thing to patients. Identifying medical students with any other term than 'medical student' is, as the authors suggest, obfuscation. By the standards of contemporary America, to obfuscate intentionally or to dissemble outright (a nice word for 'lie,' which is probably more appropriate) in ways that imply (or state) that medical students are physicians is blatantly unethical.

The editor proposes that students consider what they would say if they had nurse or a doctor as a patient. "Students who feel justified in calling themselves 'doctor' when the patient is not medically sophisticated, should also be willing to do so when the patient is a licensed medical professional."

The editorial continues:

If we want patients to trust us, we must be honest with them.... How do faculty describe the people they teach? Do we say, 'I'm going off to give a lecture to student physicians'? How do these students describe themselves? Do they say, 'I'm a student doctor'? Or 'I'm an MD student'? I think not. No, we teach 'medical students,' they refer to themselves as 'medical students,' and that is how they ought to be identified to patients....[21]

Program leaders doubtlessly claim to hold honesty as a (nearly) absolute rule. If they intend to deceive vulnerable patients who enter the walls of the medical center seeking care, one must wonder why. I suspect that the rationale is based on the belief that overstating medical students' status will more likely get patients to accept care from medical students. This study shows clearly that such deception works, that the use of obfuscatory descriptions does, in fact, change how patients perceive the medical qualifications of their caregivers.[22]

The authors of the original paper seem to agree: "Creating a habit of betraying the fiduciary trust for reasons of self-interest is ethically dangerous."[23]

The editor asks:

Should we accept and support a system that continues to perpetrate historical inequalities reminiscent of the older days of medical education, in which patients - poor, often people of color - accepted being 'guinea pigs' to obtain free healthcare? Do we want to teach our students that their best interests are served by hiding their identity?[24]

 


 

[1] Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors. New York, NY: Scribner, 1996:174.

[2] Fjerstad v. Knutson, 271 N.W.2d 8, 13-14.

[3] Beatty, ME and J Lewis. Letter. Academic Medicine 70(1995):175-176.

[4] Epstein, LC and E Guadagnoli. "Introducing Medical Students to Patients." Rhode Island Medical Journal 74(1991):321-326.

[5] Massachusetts Board of Registration in Medicine, Rules and Regulations VI.3.

[6] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part I." Proceedings of the Annual Conference on Research on Medical Education 24(1985):138-145.

[7] Ibid.

[8] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part II." Proceedings of the Annual Conference on Research on Medical Education 24(1985):146-153.

[9] Cohen, DL. "A National Survey Concerning the Ethical Aspects of Informed Consent and Role of Medical Students." Journal of Medical Education 63(1988):821-829.

[10] Silverman, DR. "Narrowing the Gap between the Rhetoric and the Reality of Medical Ethics." Academic Medicine 71(1996):227-235.

[11] Beattyu, ME and J Lewis. "Inaccurate Medical Student Introductions." Connecticut Medicine 59(1995):455-460.

[12] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part I." Proceedings of the Annual Conference on Research on Medical Education 24(1985):138-145.

[13] Cohen, DL, et al. "Informed Consent Policies Governing Medical Students' Interactions with Patients." Journal of Medical Education 62(1987):789-798.

[14] Cohen, DL, et al. "The Ethical Implications of Medical Student Involvement in the Care and Assessment of Patients in Teaching Hospitals: Part I." Proceedings of the Annual Conference on Research on Medical Education 24(1985):138-145.

[15] Silverman, DR. "Narrowing the Gap between the Rhetoric and the Reality of Medical Ethics." Academic Medicine 71(1996):227-235.

[16] Greer, DS. To Inform or Not to Inform Patients About Students." Journal of Medical Education 62(1987):861-862.

[17] Marracino, RK and RD Orr. "Entitling the Student Doctor." Journal Of General Internal Medicine 13(1998):266-270.

[18] "Why Medical Students are 'Medical Students.'" Journal Of General Internal Medicine 13(1998):718-719.

[19] Ibid.

[20] Silver-Isenstadt, A. "Medical Student Name Tags." Journal Of General Internal Medicine 12(1997):669-671.

[21] "Why Medical Students are 'Medical Students.'" Journal Of General Internal Medicine 13(1998):718-719.

[22] Ibid.

[23] Marracino, RK and RD Orr. "Entitling the Student Doctor." Journal Of General Internal Medicine 13(1998):266-270.

[24] "Why Medical Students are 'Medical Students.'"

 


 

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