sBMJ | Should medical students be introduced to patients as "student doctors"?

Should medical students be introduced to patients as "student doctors"?

In the first article of a new section on medical controversies, Daniel Sokol discusses the implications of introducinging medical students as student doctors

Medical ethicists are notorious for their interest in rare and far-fetched cases. “Vive la différence!” could be an ethicist’s motto. But this is one of the most ordinary ethical issues in clinical medicine. So ordinary is it that many do not consider it an ethical issue at all. What is undeniable is that the issue—ethical or not—affects many patients, doctors, and medical students across the country.

Verbal tranquilizer

Most medical students, at one time in their training, have been called “student doctors” by their seniors. Registrars and consultants regularly boost the egos of their eager students with a taster of that delectable title—Doctor. Many patients are led to believe that “student doctors” are genuine doctors and go on to address them as such for the rest of the consultation. More than encouraging the students, the title also serves to reassure the patient that the nervous looking youth before them is not feebly attempting to assault them but is examining them. The title acts as a verbal tranquilizer, putting anxious patients and students at ease and “getting the best” out of both parties.

Where’s the problem?

Throughout their hospital stay, however brief, patients are asked many questions by healthcare staff. It can be an exasperating experience. A weary or irate patient is more likely to answer questions if asked by a doctor. Introducing students as “student doctors” thus increases the compliance rate and provides opportunities for students to practise their history taking. So what is the fuss about if no one is harmed by the benevolent subterfuge? Is this another case of an ethicist creating an ethical issue out of nothing?

Subverting autonomy

Arguably, patients have a duty to allow medical students to train on them. This is the price to pay for technically competent doctors. To use the philosopher Kant’s distinction, this volunteering is not a perfect duty (that is, it doesn’t have to be discharged at every opportunity), but an imperfect one (it must be discharged only some of the time). If medical students masquerade as doctors it becomes difficult to fulfil one’s imperfect duty. As a duped patient, I may be more dutiful than I need to be. My right to refuse helping on this occasion is stripped away from me. My autonomy is subverted by the false belief that I have no choice.

Deceiving patients

Deceiving people is generally a bad thing. It tends to diminish trust (if discovered) and violates the deceived person’s autonomy by imposing or maintaining a false picture of the world. Introducing students as “student doctors” is not factually false. It may not even be an act of deception if the senior doctor does not intend to mislead the patient. Yet, it may well be unintentionally deceptive. Many patients are convinced that the student is a doctor and behave accordingly, perhaps disclosing sensitive information that they would not otherwise disclose. Patients have duties to doctors that they do not have to medical students. Clear identification allows patients to exercise the appropriate duties to the relevant people.

Deception in medicine is not always wrong. There are exceptional circumstances when benign deception is preferable to an adverse truth, or where ambiguous words can defuse or prevent a crisis. Yet the clear wrongness of deception is a good reason to avoid encouraging the practice among medical students, lest they get into bad habits. Consultants who encourage deception so early in the medical careers of students set an undesirable precedent and make dubious role models. Honesty is intimately linked to trust in the doctor-patient relationship. If I discovered that the four youthful doctors who just performed scrotal examinations on me were, in fact, verbally disguised medical students, I would be rather annoyed. My general trust in the medical profession would be diminished. Although some deceptions are unavoidable, this obfuscation is unnecessary. As most patients are prepared to help students if asked directly, there is simply no need for verbal trickery.

You do know this is my first day,dont you?

Conclusion

Just as medical students would not be presented as “student doctors” to medically qualified patients, neither should they be to any other patients. Patients should be treated with equal respect, whatever their medical sophistication. Boosting the egos of medical students, providing them with practical experience, and reducing the anxiety of patients—these laudable aims can be achieved in ways that do not subvert autonomy or betray patient trust.

Daniel K Sokol, coauthor of Medical Ethics and Law, Surviving on the Wards and Passing Exams
Email: daniel.sokol@talk21.com

studentBMJ 2005;13:309-352 September ISSN 0966-6494

Responses published this month

Articles	Responses
EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Fiona Martin (September 1st, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Katie Clayton (September 1st, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	David Anderson (September 11th, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Charlotte Davies (September 15th, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Elizabeth Wolstenholme (September 29th, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Abeyna Jones (October 2nd, 2005) Read this response

EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)	Jamie Fryer (October 4th, 2005) Read this response

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Fiona Martin (September 1st, 2005) 4th year medical student, University of Nottinghammzyxfmm@nottingham.ac.uk
	While I don't fundamentally disagree with the points made in this article, I must admit that I have recently taken to introducing myself to patients as a student doctor mostly because I became fed up explaining what a medical student was. In my experience, patients seem to understand the term "student doctor" quite well - in the same way that they understand the term "student nurse", but the term "medical student" seems more ambiguous and open to interpretation. Inevitably there are some patients who will only hear the word "doctor" and feel that I am more qualified than I am. This doesn't happen very often, but the result is that I get asked questions about management and prognosis that I am not qualified to answer. When that happens I make it clear to the patient that I am still learning and that they need to ask one of the doctors. So what we seem to be comparing is a term that many patients find confusing and another that on some occasions may lead to students being credited with more knowledge, experience and responsibility than is justified. In the latter scenario, the onus is on the student to be professional and know their limits. That is a skill and a responsibility that people of all levels in medicine should develop and exercise. If we go around abdicating what little responsibility we have as students and going to great lengths to point out to patients how unqualified we are or how little we know, how many of them will trust us to take blood or put in a venflon or ask them questions about sex? Responsibility doesn't start on the day we qualify.

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Katie Clayton (September 1st, 2005) Second year GEP, St George's Hospital Medical Schoolkate_clayton@btinternet.com
	Dear Editor - I read this article with interest, and agree wholeheartedly with the underpinning ethical principles. However,the author makes some assumptions which I wish to challenge. Firstly,there is the assumption that patients more clearly understand the meaning of 'medical student' as opposed to 'student doctor'. When I gained my place at medical school I was repeatedly asked "to study what?" , even by people who were relatively 'medically sophispicated'. When I was a student nurse, people rarely mistook me anything other than a trainee, and of course I promptly corrected them if this was the case. Furthermore, there is a implication in the article that some sort of conspiracy exists to 'dupe' patients into participating in consultations with students. It is not more likely that that they consider the term 'student doctor' easier for the patient to understand than 'medical student', and are in fact attempting to promote patient autonomy rather than massage a student's ego? Ethicists do not have the monopoly on ethical behaviour!

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	David Anderson (September 11th, 2005) 5th year medical student ,University of Auckland, New Zealanddee_jay_ay@xtra.co.nz
	Sir, I must disageee with the main argument in what was a very interesting and thought provoking article. I always introduce myself as a student doctor, indeed, it says on my name badge that I'm a student doctor. I do not feel that it is decieving, infact I feel that it clarifies my role to the patient more than the title medical student. I am studying to be a doctor, just as a student nurse is studying to be a nurse and a student radiographer is studying to be a radiographer. I actually get quite worked up when I am seeing a patient with a colleague and they introduce themselves as "a 5th year medical student". To the overwhelming majority of patients this is a a totally superflous utterance that conveys no information whatsoever about my colleague's role or responsibilities. Most patients do not know that medical students are studying to become doctors (as one of your previous correspandants has pointed out). I too am more often than not asked what I want to be when I graduate after telling someone, at a party for example, that I study medicine. The statment "a doctor" is usually met with surprise. I know of many female colleagues who are still asked what kind of nurse they want to be when they introduce themselves as medical students. The title "student doctor" makes it totally clear that we are studying to become doctors and also identfies as the junior members of the healthcare team that we are.

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Charlotte Davies (September 15th, 2005) Fourth Year, Medical Student , Leeds Medical Schoolugm2cd@leeds.ac.uk
	I read this article with interest, as it is something that my friends and I have often discussed. Whilst I agree with all the points mentioned above, like several of the other responders, that the term 'medical student' is a lot more ambiguous. Many a time I have introduced myself to a patient as a medical student, only for the patient to say 'thank you nurse' at the end of the conversation. When I have introduced myself as a student doctor, for clarity reasons, I have rarely found a patient assuming that I'm qualified- possibly because I have a name badge saying 'student doctor' prominantly displayed. I still believe that 'Student Doctor' should be used - Student Nurses are introduced as Student Doctors, why shouldn't Student Doctors?

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Elizabeth Wolstenholme (September 29th, 2005) 5th year medical student , Manchester medical school and Keele university medical schoolelizabethwolstenholme@hotmail.com
	Dear Editor, It is with respect of the author’s position and expertise that I have to disagree with some points made in this article. While I appreciate the view and agree with the point that intentionally deceiving patients into believing medical students are more qualified than the truth is morally and ethically wrong, I do not believe the term "student doctor" would necessarily be used with this in mind. Indeed, in the cases I have experienced the term being used, there has be no malicious or deceptive component to it. When I started my clinical placements in the third year I remember being advised to use the term "student doctor" while introducing myself to ensure clarity of my role; although this proved a little futile as my identification badge states I am a "medical student". In my experience patients do not confuse the term "student doctor" with "newly qualified doctor". Instead I have commonly encountered patients mistakenly thinking "medical student" meant "student nurse". Furt! her, the term "student nurse" is not met with the same confusion and perceived immoral undertone, thus why should there be an issue with the term "student doctor"? I am sure we have all encountered peers at medical school strive to be perceived as more qualified than they actually are, these represent immoral/unethical individuals rather than students as a whole. Indeed, I do not believe a term of identification could convey this deception alone. Finally, I do believe there is an issue with patients not understanding the knowledge, qualifications and limitations of the role of the medical student. I believe this has little to do with introductions; many patients probably do not retain the name and status of each professional they are in contact with. Instead I believe the misconception often arises due to the situation in which medical students come into contact with patients. In hospitals patients are often met on ward rounds or in clinics, where they may be asked technical-sounding questions and are viewed part of a highly qualified and trained group. Thus, if we want to stop deception of patients and misinterpretation regarding status and qualification we should (1) focus on the detection and management of such medical students who intentionally deceive staff and patients rather than, the often unconscious and innocent, use of the term student doctor and (2) ensure patients are education regarding the roles of eac! h member of the team.

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Abeyna Jones (October 2nd, 2005) 5th year medical student , Nottingham Universityabeyna.jones@gmail.com
	The label of a 'student doctor' is not merely a form of 'ego boosting' for medical students, as the editor may have suggested; it represents a) recognition that we are studying to become medical doctors and b) we are responsible individuals who are, to varying degrees, may contribute towards the daily management of patients; arguably part of the firm. We are not 'masquerading as doctors' as many may believe. In some specialities we are made to wear white lab coats as a form of identification (forgetting our ID badges which clearly state who we are), out of fear that we may be identified as a doctor. It is questionable why even at this stage we are not trusted to correct a patient if they do assume incorrectly, or that when divulging information in a clinical setting the fact that we are also bound by the Hippocratic Oath and the utmost importance of confidentiality is not considered. In response to the previous comment made by Fiona Martin, the term 'student nurse' is widely recognised and accepted; especially amongst medical staff because they work shifts in hospital on a regular basis, are paid a basic 'wage' and are integral to hospital nursing system. I remember a time when I was in A&E with a fellow medical student colleague with two other student nurses and one of the staff nurses asked all the 'students' to leave, consequently ushering myself and my colleague out of the bay. On another note, our presence in any clinical setting is largely determined on how we are introduced by our seniors; sometimes the health professional (usually a doctor) does not explicitly give the patient a choice and merely introduces. The majority of the time, patients seem to have little quarrel in our presence and even welcome it, however on few occasions we may be presented as, what I refer to a 'negative' entity; "There is a medical student here today but don't worry I can send them away if its a problem". If patients were given insight into our role in the hospital and general learning objectives, they would be able to make an informed decision on our involvement in their management. The teaching hospitals in which we continue our training should be responsible for this in some respects, so that we can avoid the consequences of misinterpretations of the terms 'student doctor' or 'medical student', possibly causing detrimental effects on our already limited clinical experience.

	EDUCATION Should medical students be introduced to patients as "student doctors"? Daniel K Sokol (Sep 2005)
	Jamie Fryer (October 4th, 2005) 4th year 'student doctor' , GKTjamie.fryer@kcl.ac.uk
	Dear Editor - In the modern NHS there really is no such position as a 'Junior doctor'. The title is quite meaningless. And yet great deal of patients and medical staff alike recognise and use the term to mean Pre-Registration House Officers or even Senior House Officers. The same applies to student doctors. The word 'Student' hits you rather quickly. Indeed, it is the first word of the title. I have found few patients who don't understand its meaning, including many from outside of the UK. A common 'small-talk' type question I hear from patients is "so how much longer have you got left?" A question which implies they understand the long educational process all hopeful doctors take towards qualification. It would seem to myself to be rather a strange concept to scrap the informal title of 'student doctor' and to go from being introduced formally as 'medical student' (on your first day of medical school to the day before you receive your finals results), to being introduced as 'Junior Doctor/House Officer' just a few weeks later. The term student doctor in my mind distinguishes those who spend their days deep in the anatomy dissection and physiology lectures of pre-clinical years to those who spend their days going from tutorials on restrictive lung diseases and trawling the cardiac wards searching for nice clinical findings. It distinguishes those who could tell you in great detail the different pathogens that can cause a UTI, but would be clueless to answer the simple clinical question "What are the symptoms?" My last point would draw on one of the points in the article - the "four youthful doctors who just performed scrotal examinations". Having seen 3 SHOs and an SpR crowding around the bedside of a gentleman with 'interesting signs' being taught by the consultant, I think it would be pertinent to remember that in medicine we rarely stop learning from those more authorative than ourselves. Is it therefore really fair to suggest that a 5th year "medical student's" scrotal examination is 'training' whereas a PRHO "Doctor's" scrotal examination is not?