ethics

Day 269: I am not a doctor

Amanda Xi

Today’s inane image of the day:

Have you tried the new Mocha Cookie Crumble Frappuccino yet? It’s like blended cookies and happiness all in a cup. Plus, you can get them for half off between 3-5PM from now until May 13. [Today’s entry actually pertains to Starbucks…]

This morning started off like any other. I parked my car, walked into Starbucks and pulled up my iPhone app while waiting in line. The usual suspects were already there — the elderly fellow that always flirts with the baristas, the business man with his freshly pressed suit and the tired-looking mother. As I approached the counter, I ordered my usual summer morning beverage and went through the motions to pay.

As I meandered toward the pick up counter, one of the baristas grabbed my attention: “Hey, Amanda! You’re in medical school, right?”

I stopped in my tracks and turned my attention toward him. Immediately, I braced myself for the worst; in our Medical Humanities course, the professors warned us that upon entering the profession, family and friends would suddenly start turning to us with their medical questions. We were cautioned that because there would be no escaping the situation, we needed establish an appropriate response to the request. But never did I imagine that as a first year medical student, an acquaintance would turn to me for advice.

“Yes, but…”

He cut me off. “I have lower back pain that radiates down my leg…”

The gears in my head started turning. I thought back to my latest clinical experience — one of our patients described a similar chief complaint and during our discussion with the preceptor, we discussed differential diagnoses for that particular symptom. I tried to clear the cobwebs clouding my knowledge of Anatomy and Neuroscience and considered the nerves that could be affected. I wondered if there was an inciting event that precipitated the pain. But in the end, although these thoughts raced through my mind, I never had any intention of sharing them.

“…and I was wondering…”

As I stood there listening to him, it struck me how entering medicine was almost synonymous with being entrusted with a stranger’s thoughts, feelings and ultimately, their life. We are taught how to ask open-ended questions and how to probe for the whole story. We are told to trust our instincts if something just doesn’t feel right. But for the most part, patients come prepared to talk about what is bothering them because it is embedded into our culture to have an unspoken confidence in physicians.

As medical students, we reside in a paradoxical limbo. In order to become competent physicians, we need to interview patients and suggest diagnoses. We need to try procedures or practice them to obtain perfection. However, because we have little to no experience, patients tend to shy away from our [supervised] care. Additionally, at this early stage of training, most of us do not feel confident in our knowledge to provide even basic explanations of diseases.

When he continued with, “…what kind of doctor should I go see?” I let out of a sigh of relief and directed him toward his internist. This time, I was posed with a question that I could answer. But the situation gave me an opportunity to consider how I would respond to future questions that I am not qualified to answer. In class, our professors explained that when faced with a medical question outside of the hospital, they defer to the patient’s internist because they do not know the details of their medical history. Today, had I been faced with that situation, I would have responded the same way but with the added note that I am just a medical student; I am not a doctor.

Double header: ethics of physician shadowing & the waitlist limbo

Amanda Xi

800+ page views?! Thanks again for visiting!

Today’s blog topics: ethics of [pre-medical student] physician shadowing and the waitlist limbo.

Ethics of [Pre-Medical Student] Physician Shadowing
Somehow an SDN thread on physician satisfaction with the profession led to a MEDLINE search for physician satisfaction, which then led to an article in JAMA that then resulted in stumbling upon a commentary entitled, “Shining a Light on Shadowing” by Elizabeth A. Kitsis, MD, MBE [where MBE is a Master in Business and Engineering, apparently].

Basically, the piece cited four concerns about shadowing [italics are quoted from the commentary]:

  1. a physician’s fiduciary obligation: “How is a patient’s welfare served by having a college student present during an appointment with his or her physician?”
  2. privacy, confidentiality, HIPAA: “In addition to their fiduciary obligations, physicians have other duties to their patients that are breached by college student shadowing, including maintaining privacy, maintaining confidentiality…“
  3. patient consent/coercion: “Physician shadowing by college students also may involved subtle coercion of the patient. To maintain his or her rapport with the physician, a patient may feel compelled to allow students into the examination room if his or her physician makes the request.“
  4. student misrepresentation: “It is possible that manipulation or deception may be used (unconsciously or consciously) to gain entry for a college student into a patient examination room… are college students simply introduced as ‘members of the team’ or generic ‘students,’ which may incorrectly lead patients to assume they are medical students?“

While I understand the validity of these concerns, I find it incredulous that this could be posted in this day and age when physician shadowing [or something similar] is just about a must for entrance into medical schools. Not to say that the author isn’t aware of this [she does mention its importance in the application process]. Happily, there were a couple of responses from other practicing physicians that did a great job countering each of these concerns [though, sadly, Kitsis. rebukes them with the same “what if” scenarios…]

My personal rebuttal:

  1. a physician’s fiduciary obligation: I agree that this obligation may be in question when asked how the patient benefits from a college student’s presence, but I’d argue that a large proportion of students who shadow physicians end up pursuing medicine, and thus, the benefit may not be apparent for that single patient, but will be in the long run. For the most part, I believe that many pre-medical students who shadow physicians do not use the experience as a way to discover career paths, but as a confirmation of their choice.
  2. privacy, confidentiality, HIPAA: This is definitely a big one, but in all my shadowing experiences, I have always signed and agreed to the rules designated by HIPAA, making my presence similar to other healthcare professionals [though, admittedly, I believe that medical schools do delve into the issues that surround HIPAA, so I may revisit the topic later to discuss if I had any revelations after learning more that would make me see this issue differently]. Furthermore, we are all patients ourselves and should understand how important patient-doctor confidentiality is.
  3. patient consent/coercion: While I agree that a physician may subconsciously have a bit more weight in convincing a patient to allow a student to shadow, in today’s day and age, many people are a lot more vocal about their concerns. Admittedly, I do not have a good rebuttal to this one.
  4. student misrepresentation: In pretty much all of my shadowing experience I have had the physician introduce me vaguely as a “student” — while I understand that there is a fine line between what can be deemed ethical in this case, I do believe that this specific case does not necessarily cross it. The term is up for further dissection if the patient wishes [I have been asked what I am studying in school, so the possibility that I am not a medical student has crossed patients’ minds] and I feel that especially because the student is doing absolutely nothing except being a fly on the wall, there is no harm done. Though, I do believe that pre-medical students should be introduced as such in all cases.

My personal experience with shadowing has been extremely positive and helped confirm my almost-lifelong dream of becoming a physician. While I had been searching for shadowing opportunities earlier on, I did not secure an opportunity until right before I submitted my application. Although I was able to include my first shadowing experience in my AMCAS, I did not formally mention my additional experience anywhere [though, one of them did work its way into one of my secondary essays].

I shadowed a cardiac interventionalist, pediatrician and internal medicine physician. Although I cannot say I am particularly enamored with primary care, the opportunity to see primary care physicians in action made the  challenges I had read online, real. It truly is one thing to nod and agree with the patient load and frustrations that primary care physicians have to face, and it’s another to watch an infant’s mother refuse vaccinations or an obese patient refusing to change her diet despite being plagued with a variety of cardiovascular-related ailments. While the cardiac catheterization procedures were interesting, I cannot say that they really sparked my interest [I was just really cold in the OR and really happy that I had a lot of lead on to keep me somewhat insulated].

This all being said, I’d like to propose some “shadowing etiquette” tips:

  • Dress and act professionally — patient impressions are important, especially if you aren’t a doctor yet
  • Make sure you’ve signed a HIPAA statement and have discussed its meaning with the physician you are shadowing — might as well address this ethical issue
  • Ask the physician beforehand if you can be introduced as a pre-medical student to reduce ambiguity
  • Stay quiet while with the patient — while you may suspect that the patient has all the classic signs of strep throat, you aren’t a doctor… yet
Let me know if I missed anything, or if you have a physician shadowing experience that one of these issues arose during.
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The Waitlist Limbo
As some of you may already know, I was waitlisted at 3 schools [OUWB, NYMC, MCW]. Keep in mind that my application was late in the cycle, so one of my interviews [MCW] was for a spot on the waitlist [more details on how this works later].
Unfortunately, the only school that outright accepted me [Wayne] did so in early May, so I was in waitlist limbo from March until May. Undoubtedly, the kid on 11 waitlists on SDN who has been on those lists since October had it a lot worse than I did… but 2 months of just waiting around trying to figure out a back-up plan for the fall was pretty traumatic. Especially since most of us pre-meds are neurotic and crazy… after sprinkling in the “unknown future” factor, it really magnifies the personality.
Honestly, I was not myself after I received word about my first two waitlist decisions. As some of you may already know or will soon know, after investing that much of yourself into this process, and realizing that there is a high chance that you will be unsuccessful the first time, it tends to be hard to find the energy to keep going. I know that had I been unsuccessful, I definitely would have needed to take a serious vacation before starting from square one.
This all being said, here are some important things to keep in mind while chilling in waitlist limbo:

  • A waitlist is not a rejection. I promise you, people get off the waitlist and make it to medical school. Many times, a waitlist could just be because you were late in the cycle and there are no seats left in the class [such as MCW].
  • Be proactive. Don’t be crazy and call the admissions office 3 times a day asking if there has been waitlist movement or if your application is with the committee or if you will be accepted. Do call and check in every once in a while [if the school permits — just ask if you are unsure] so that they become familiar with your name when it comes up.
  • May 15 is a very special day — but probably not for you. While this date is the deadline for multiple acceptances [people holding more than one must rescind all of their acceptances except one, but may remain on waitlists], chances are the admissions team needs to re-evaluate [especially if we’re talking about an unranked waitlist] or prepare for making acceptance calls. Not to say that no one gets off the list on that date, but a lot of people don’t hear anything until a day or more later. I received my OUWB call a couple of days following the deadline.
  • Update letters/letters of intent. I sent in one update letter to OUWB [and look where it got me!]. I do not suggest sending in anything “fluffy” — as in, don’t make an excuse to write them a letter [two more hours in a clinical setting probably won’t boost your application significantly…]. Send in meaningful updates — I personally had an international conference presentation submission accepted as well as received an award, so I made sure to include those in my letter. My letter was not a letter of intent. It is ridiculously important not to lie in these things — if you would not rescind your application from every other school once this school accepts you, then don’t say that they are your top choice. However, I did mention that OUWB was one of my top choices [which it was]. I do not believe that letters of intent make a huge difference, but sometimes they could tip the scales in your favor. 
If you have any questions about the above, let me know! I’d love to make this blog a relatively comprehensive resource.
Finally, some schools will do a couple waitlist-only interview days such as MCW. A good rule to follow with these is that if you do not yet have an acceptance, go for it since every interview gives you a better chance of getting in eventually. Since I did not yet hear any good news, I booked myself a plane ticket and hotel room and headed to MCW for their last waitlist-only interview day. The way that MCW’s waitlist-only interviews work is that you can receive two post-interview decisions: waitlist or rejection. Since their waitlist is tiered [and probably ranked… but they’ll at least release your tier] and they generally fill a quarter of their class from the waitlist, you have a good chance of being accepted. Furthermore, you can be placed higher than someone who interviewed earlier in the cycle [non-waitlist-interview], and thus end up in a better position. 
I really loved MCW when I visited and I saw myself going to the school — I believe that this was pretty apparent during my interview and felt like both the professor and student interviews went well. Apparently, my feeling was correct because when the tiers were released, I had been placed in the top one. I received the acceptance call in early June.
I’ll talk more about my decision to attend OUWB over my 2 other acceptances later!