Monday, November 22, 2010

Newsflash: Medical Students Assist in Medical Care at Teaching Facilities

About a week and a half ago, The Dallas Morning News published an unfortunate case of medical mismanagement, mainly dealing with a lack of oversight from attending physicians over residents and medical students.
"Even students – who have yet to graduate from medical school – provide key care, sometimes without direct supervision....
...(the) surgical consent form had warned that (the patient) could face 'blood vessel or nerve injury' complications. It also noted that students might be involved in (their) 'surgery and surgical care'."

They also released a spin-off article stating that ethicists generally feel that patients around the country are not made aware of medical student involvement in their care.
Many hospital patients don't know who's caring for them at any given moment, said Dr. Lisa Soleymani Lehmann, a Harvard Medical School assistant professor who runs the Center for Bioethics at Brigham and Women's Hospital. Many don't distinguish between residents, who are degreed doctors getting paid, on-the-job training, and students, who are unlicensed and still in medical school.

"There's a tremendous amount of confusion," Lehmann said.

She has surveyed about 200 Boston-area patients who underwent operations in which students participated. Half of the patients didn't even realize that medical students had been in the operating room, she said.

Lehmann said many hospitals' consent forms have improved in recent years and now tell patients that medical students will be "involved" in their care. But patients "don't know what that means," and many don't even read the forms, she added.
Over the past week and a half, I have had an internal struggle about what to write about this event. The specifics of this case are quite tragic and should never happen anywhere. At first I was rather annoyed that the author of the original article happened to release the spin-off right away while generalizing all medical students and implying a general lack of communication around the country. Could the author use such an unfortunate case as a stepping block to create generalized anxiety throughout the nation?

As previously mentioned in my burnout blog post, our medical education is already compromised by a feeling of uneasiness from our attending physicians with their practice of defensive medicine. If we place further restriction on our medical training because of a select number of medical mismanagement cases, will we continue our travel down the slippery slope and overall loss of educational opportunities? Will intern year be the new 3rd and 4th year of medical school? (not to mention the possibility of increasing the number of years of residency!?)

Take a look at AMA Opinion 8.087 - Medical Student Involvement in Patient Care. It basically states that medical students need to be identified and patients need to be disclosed as to how the students will be involved in their care, whether it is in the community health center taking an H&P or simply "driving the camera" in surgery.

After taking some time to settle down and think about my own medical training experiences, I have realized that there are definitely ways to improve communication with all members of the team towards patients.

From attending physicians to medical students, it is quite helpful to know the extent of our involvement, especially in surgery. This is not an easy task, as some attending physicians may provide student opportunities during procedures on the fly at their own discretion. Again, this is a difficult task as there is always a first time for doing something and assessing ability is impossible unless the task actually occurs in real-time.

When is it appropriate to drill a pin into a broken bone? How do we know when a student is ready to suture? Are students more prepared to advance their skills on the last rotation of 4th year or as a resident during the first week of internship?

From attending physicians, residents, and medical students, we all need to communicate better towards patients in regards to our role in patient care. Consent forms that are vague and do not provide specific detail are not adequate for patient satisfaction or overall patient safety. We need to identify ourselves to our patients and not just disclose the side effects of medication or the risk of infection and bleeding, but each of our roles in providing safe and effective care.


  1. Good post. So what is the number of patients needed to treat partly with a medical student before a life is saved and the number needed to treat before a life is lost? NNT vs. NNH? Further studies will be needed.

  2. Shocking. I read the piece from the perspective of a patient. You, the author of this blog, read the piece from the perspective of a medical student/doctor. Different things are important to you - you seem to see it as an encroachment on your ability to learn - I see it as the current system in place at this hospital harms patients - and in the instance of this patient - no one cared enough to take the time to determine if the patient was just complaining or if maybe - just maybe - her reports of pain and discomfort warranted further review. I wonder if her status as a housekeeper, implication of lower income - probably a person of color - contributed to her care. I'm guessing yes.

    Doctors/med students are busy people. It's so much more efficient to stereotype, categorize, make snap judgments than to stop and consider individuals and their reports of their own conditions individually. "She doesn't know what she's saying. She just wants more pain medication - she just wants to get high - her pain isn't real."

    I can tell you, from my own experience as a surgical patient in a teaching hospital (Johns Hopkins), that the residents who rounded on me post-op didn't even wait for me to answer one question before they went on to the next question on their list. I was a body - a procedure - a checklist - and it seemed to only matter that they check the boxes - nothing else. I'm fortunate. I'm educated. But, I know, in my bones, that if my attending surgeon had actually attended my surgery, I would have had a better outcome. It was a lie from the first - and I asked - specifically asked because I was reluctant to have the surgery in a teaching hospital, and could have chosen to go elsewhere - and he lied - bald-faced lie. I chose my surgeon specifically. It was bait and switch. And it was wrong.

    One more thing - there's a difference between a bad outcome and a mistake resulting in serious harm. This case is the latter. No one is perfect, we all make mistakes - but we also have to live with the consequences of those mistakes. Doctors don't get absolution for their errors - they still have to face them, own up to them, and make them right. The only reason this woman can't get an attorney to take her case is because she won't make a sympathetic plaintiff. If she were white, a little younger, educated, and reasonably attractive - they'd be all over it. You know I'm right.