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What do I do now?
Commentary Every medical student faces this issue at some point in his or her training. I faced it in my first month as a medical student. One of my fellow students passed round his new business cards, which said "Doctor Bloggs" and urged us to call each other doctor, for practice. This bit of deception, even if it is was only self deception, disturbed many of us, and we persuaded him to stop. The temptation to deceive arose again when we started our hospital duties with patients. We were still students, with no medical qualifications, but the real doctors supervising us introduced us to patients as "doctors." Should we have objected to this, risking embarrassment for our supervisors and possible reprimand for ourselves? And anyway, after so many years of thankless toil to get where we were, wasn’t it about time that we were given a little respect, even if it was a bit premature? The truth was, most of us secretly liked it. It gave us a taste of the respect and power that we knew would soon be rightfully ours.Are there any legitimate reasons for this deception? One argument is efficiency. When introducing a team of trainees on hospital rounds it becomes quite cumbersome to describe the training state of each. Also, most patients do feel more comfortable and comforted in the hands of a doctor than those of a student, and might be more apt to comply with the treatment plan. What is wrong with this? From our perspective, very little, aside from some qualms about the slight dishonesty involved. The problem becomes obvious when we change places with the patient"now how does this slight dishonesty look? I am being introduced to the doctor who has my health in her hands, and am told that she is "Doctor Jones." I have no reason to think that she is not a doctor. I have every reason to think that she has some experience with my illness, with the medications that she is prescribing, and with the tests she is ordering. If and when I find out that she is still years away from even having a licence to practise medicine, that she has in fact never treated my illness before, I am apt to feel angry, afraid, and betrayed. When looked at from the patient’s perspective, we can see that the right to know the training status of those providing our care is part and parcel of the informed consent process. Informed consent is not just a form to be signed. It is the process of giving patients all the information relevant to their care, all the information they need to say yes or no to a given course of treatment. The identities and roles of the members of the care team can be relevant and patients should have a right to say no to this arrangement as well as a right to agree to it.Divulging your training status can have a direct beneficial effect for the student or junior doctor. It can be uncomfortable pretending to be something you are not. Once the patient knows what our training status is, their expectations are likely to be more in line with what we are in fact able to do. We will then be more comfortable admitting when we do not know the answer or cannot perform a procedure and need to ask for help. Kate Christensen internist, Permanente Medical Group, northern California
Commentary I believe that questions of personal identity constitute a central moral problem for students of medicine. The circumstances of medical training provide a perfect medium for identity deficit crisis. In the effort to become doctors, medical students strive to establish a radically new component of personal identity. In the early clinical years they are often asked and expected to do the things that doctors do, as if they were, in fact, already doctors. They approach patients, in white coats, asking serious questions and examining exposed flesh. They are frequently expected to generate sophisticated diagnoses and treatment plans, and to impart medical wisdom shamelessly to patients. Of course, if they were up to these tasks there would be no need for medical training. Hence, there is fertile ground for an identity crisis. It may be reassuring or even exhilarating for medical students to introduce themselves as "Doctor," but the practice strongly countervails one of medicine’s core values"honesty. As such, it fails notmerely because it is objectionable, but also because it does not succeed in ameliorating the identity crises. Calling yourself "Doctor" is not an effective way of alleviating anxiety about insufficient knowledge or skill. A more likely result is a magnification of feelings of inadequacy and guilt. Regrettably, the practice of introducing medical students as doctors or pretending that they are doctors is common. This practice is based outwardly on concern for the wellbeing and comfort of patients. The assumption that patients will be unable to handle the generally benign presence of medical students is ungrounded and is a classic instance of beneficence twisted into paternalism. Certainly some patients will have misgivings about students in certain situations. Often, these misgivings can be corrected with frank discussion. I frequently tell patients that having a medical student involved in their care is a distinct advantage. Since the caseload for medical students is much smaller than for doctors, the patient gets more attention than would normally be available. Often a diligent student will uncover crucial historical information orpursue fruitful lines of inquiry just because he or she has the additional time. Meanwhile, double doses of attention are garnered from the doctor, who must assess the patient while also addressing the medical student’s assessment. The vast majority of patients will acknowledge this benefit. And what if patients staunchly refuse to be examined by students? No doubt, this situation will arise. But it is uncommon. After explaining possible disadvantages that patients will suffer under such an arrangement, it is probably best in these cases to excuse the medical students.
Perhaps the practice of deceiving patients about the status of medical students is ultimately motivated more by a desire to avoid discomfort to doctors and students than it is for the benefit of patients. If so, the practice is clearly unjustified. As the testimony of the medical student in our case illustrates, this deception is (and should be) a source of moral anxiety for students. Even if students and faculties feel better in the long run when they execute such deceptions, the moral imperative in medicine is primarily to benefit patients. The duty of beneficence, in turn,requires honesty and the cultivation of trust. If a certain amount of embarrassment or other personal discomfort is required in order to preserve integrity then so be it. Griffin Trotter assistant professor of health care ethics and of surgery, Saint Louis University Health Sciences Center, St Louis, Missouri
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