NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion. Please check back soon for updates!
Authors:
Kelly A. Edwards, PhD, Affiliate Professor, UW Dept. of Bioethics & Humanities
Thomas R. McCormick, DMin, Senior Lecturer Emeritus (deceased), UW Dept. of Bioethics & Humanities
Clarence H. Braddock III, MD, MPH, Director, Bioethics Education Project
Core clerkship material for: General Curriculum
Topics addressed
- What should I do when my preceptor introduces me as "Dr. Miller"?
- How should I respond when an intern asks if I want to practice a procedure on a patient who just died?
- What if I see my resident or attending doing something "unethical"?
- Is it ever appropriate to do a procedure for the first time without supervision?
- I'm not sure how I feel about "using" vulnerable patients as teaching patients. Are we taking unfair advantage of people?
- Other students have (unauthorized) access to last year's killer exam. Should I look at it?
- I'm noticing what looks like addictive behavior in one of my classmates. What should I do?
As a medical student, you may encounter some troubling issues specifically related to your position as a physician-in-training. Often, these issues can arise unexpectedly or in time pressured settings. It can be helpful to think through what you will do (and become familiar with some respected opinions) before you feel you are stuck between a rock and a hard place. This topic page address some of these concerns and allows you the opportunity to think through what you might do in these situations.
If you are particularly troubled with any of these issues, please contact our counseling office (616-3023) or feel free to post a "case" to the discussion forum on this website by sending an e-mail.
What should I do when my preceptor introduces me as "Dr. Miller"?
Some community preceptors prefer to introduce their medical students as "doctor" because they feel it encourages patient trust. However, it is important to recognize that by calling yourself "doctor," you are misrepresenting yourself to the patient. As with other truth-telling and informed consent issues, it is appropriate to disclose to the patient what he or she needs to know. In this case, the patient needs to know you are a physician-in-training! Students have found themselves in awkward situations once the patient begins asking questions that a physician should know how to answer. At this stage, even if you clarify, "Actually, I'm a medical student, not yet a physician," patient trust may be damaged.
It can be a difficult conversation to have with your preceptors, but it is best to discuss this matter in advance. Find out what his or her expectations are. If they feel strongly about introducing you as "doctor," it remains your responsibility to explain tactfully that you cannot misrepresent yourself to patients. In the long run, patients' trust will be secured if they realize you are both being straightforward. If the preceptor insists, you may need to find polite ways to reintroduce yourself to the patient, modeling for the preceptor that direct communication is often the best foundation for a strong physician (and student-physician) patient relationship. For example, you might say, "Yes, I am a physician-in-training from University of Washington."
How should I respond when an intern asks if I want to practice a procedure on a patient who just died?
Practicing procedures on newly dead patients is a highly contentious issue. For some procedures, like intubation, students can benefit from practicing first on a cadaver. Weighing the risks and benefits, the student is more likely to harm a living patient were she to try to intubate without practicing first. No physical harm can occur to the cadaver. However, some are appropriately concerned about the disrespect that "practicing" procedures may show to the deceased patient or to the patient's family. It remains your responsibility to assure that your interactions with the cadaver are respectful and only as invasive as necessary. Most likely, the time you take to practice a simple procedure will not add significantly to the usual amount of time needed to prepare the patient's body for viewing by the family if they are waiting nearby. This is important to be cognizant of, however. (See our reference list for further discussion of this difficult issue.)
What if I see my resident or attending doing something "unethical"?
You will encounter many positive role models during your medical training. However, you will also see some behaviors and actions that are downright troubling or offensive. Because of the "team hierarchy," you may feel unable to confront someone who is "above" you or, more concerning, in control of your evaluation. However, you do still have several duties in this case. Ideally, you could talk with your resident about what you observed. Everyone has a unique perspective and your resident may have a rationale for his behavior that was unknown to you. Approaching him honestly, with simple questions, may allow him the benefit of the doubt and open up a dialogue between you.
The nature of the observed 'unethical' act determines what your obligations are. In simpler cases, it can be a matter of treating it as a negative lesson in how NOT to be a physician. In more complex instances, patient care may be in jeopardy and you may have an obligation to report the resident's behavior if he refuses to discuss it with you directly. Your attending physician or clerkship coordinator can be valuable resources as you make these judgment calls. Discussing these instances with your peers can also be helpful.
Is it ever appropriate to do a procedure for the first time without supervision?
The "see one, do one, teach one" model of medical training has become something of a urban legend. However, on a busy service, you will be probably be asked to "go consent Mr. Jones" or "just start a line on Mrs. Smith." If you have never done either of these activities before, it is your responsibility to ask for appropriate supervision before beginning the procedure. Emphasize your interest in learning the new skill as well as your interest in learning it under the best conditions possible.
I'm not sure how I feel about "using" vulnerable patients as teaching patients. Are we taking unfair advantage of people?
A necessary part of learning to be a physician, "practicing" on people sometimes feels uncomfortable. You can keep a few things in mind to minimize the discomfort you might feel. First, as with all your future patients, treat them with respect and ask permission before doing any observations, tests, or procedures. Second, remember that it is a privilege to learn medicine. When appropriate, convey your gratitude to the patients, acknowledging the crucial role they play in your education.
Listen to your instincts as well. Sometimes it may not be appropriate to do an unnecessary duplicate examination or, for example, try more than three times to start an IV line in a patient. If the patient is uncomfortable with your presence, you must respect that and ask a more senior person on your team to complete the procedure or the exam. Unfortunately, you may notice a difference in how some housestaff or attending physicians treat patients from different socioeconomic classes. It is your responsibility to attend to these patients needs with respect and compassion. The homeless man in the ER could be very lucky to have you be the one to stitch his lacerations if you are the one who will be gentle and kind. Sometimes you can put a patient at ease if you convey that you are the member of the team with the most time and attention at the moment.
Other students have (unauthorized) access to last year's killer exam. Should I look at it?
In a survey of students from the late 1980's. 58% reported cheating at least once during medical school. There have been disincentives for reporting cheating, and perhaps a general sense that "this is just the way it is." On the contrary, cheating in class is an example of unprofessional behavior. It represents a lack of fairness, lack of integrity, and can foreshadow lying in other contexts during your medical training.
As a member of a profession, you are accountable for your own behavior and for the behavior of your colleagues. The Assistant Dean for Student Affairs or the Medical Student Association (MSA) representative can field your concerns and help you develop a plan for confronting your classmates.
I'm noticing what looks like addictive behavior in one of my classmates. What should I do?
Impaired students become impaired physicians. You are entering a profession that carries an obligation to its members for self-regulation. As a student, your classmate has an opportunity to seek help before serious harm comes to himself or herself, or to one of his or her patients.
Once licensed, you will have a legal obligation to report colleagues to the medical board if they are "unable to practice medicine with reasonable skill and safety to patients by reason of illness, drunkenness, excessive use of drugs, narcotics, chemicals, or any other type of material, or as a result of any mental or physical conditions (Revised Code of Washington 18.72.165)." The UW Counseling Office or the Assistant Dean for Student Affairs can help you arrange an intervention if you have these concerns.