Tuesday, June 30, 2015

What's with pre-med students "shadowing a doctor"?

Many medical schools are either requiring or highly recommending that applicants show evidence of “shadowing” [following a doctor around] for varying periods of time. This supposedly gives a pre-med student an idea of what doctors do. I guess the schools assume that if someone has shadowed a doctor and still wants to become one, that individual is a better candidate for medical school than someone who hasn't done any shadowing.

A recent incident at a hospital in Syracuse, New York raised some serious concerns about shadowing. An anesthesiologist allowed a college student to endotracheally intubate a patient in the operating room. This was a problem on many levels. Students who are shadowing are not supposed to touch or examine patients. The patient who was intubated likely did not know that an unlicensed college student would be doing a procedure on him. And of course, there's HIPAA.

According to the article, the director of Consumers Union's Safe Patient Project, called the incident an "egregious violation of patient-doctor trust."

I've had a problem with shadowing for many years, and I'm not the first to say so. Dr. Elizabeth Kitsis, director of bioethics education at Albert Einstein College of Medicine in New York, has blogged about the topic.

She told of a male pre-med student who was introduced to patients as a "student doctor" and watched a gynecologist perform pelvic exams. The student himself said he felt a little awkward. One wonders how the unsuspecting patients would have felt had it been known he was a college student thinking about becoming a doctor.

There were many comments pro and con on both Dr. Kitsis's blog and a follow-up piece that appeared on another Einstein blog.

Dr. Kitsis co-authored a paper which found that few studies have looked at shadowing by pre-med students. She called for guidelines and a code of conduct for this activity.

Several questions come to mind.

With all the information available on the Internet, is shadowing really an effective way for college students to decide whether to become physicians or not?

Is there any research comparing career outcomes of pre-med students who shadowed doctors to those who did not?

What about the patients? Do they have any say in this? Are students who shadow introduced as who they really are?

How does a student choose a doctor to shadow? As far as I can tell, there is no quality control for this aspect of shadowing.

Is shadowing mandatory in other fields? Must one shadow before becoming an engineer [civil, railroad, or sanitation], an accountant, a fighter pilot, a shepherd, or an exotic dancer?

35 comments:

Anonymous said...

THANK YOU for this. I have gotten increasing numbers of these requests over the past five years or so. They go straight into the trash.

Being at the bedside requires knowledge about confidentiality issues and TB and other health screening. These are not issues easily managed by most clinicians.

Teaching hospitals include students and trainees into their consent forms. Our voluntary faculty, who have students come to their offices to practice physical exam skills, get assent from patients who may be pleased to assist a valued doctor in his or her educational activities but can also decline.

That brings me to my real concern here, which is the hubris of college, or heaven forbid, high school students who evidently believe they're entitled to be at the bedside of patients for whom they are doing nothing. Even better, some of them expect a letter of recommendation on top of it.

The honorable way around this is to volunteer in a hospital, clinic, or similar setting. Appropriate education and screening are built into the process. Volunteers have particular responsibilities, which earns them a place at the bedside, because they're giving and not just taking. Yeah, there may be some sort of minimum hour requirement, and that is as it should be. Four hours "shadowing" isn't enough time for anyone to know they want to be a doctor, nurse, or other health care professional, anyway.

One of the best lessons I learned from volunteering in a pediatric play room program, radiology department, and ED while in college is that techs, nurses, therapists, dieticians, and a whole host of non-physicians do much of the heavy lifting when it comes to patient care. The opportunity to see the health care world, at least a little, through their eyes has been incredibly helpful as a medical student, intern, resident, and beyond. There were plenty of doctors around for me to observe and sometimes communicate with, if they had the time and inclination. Even without that, the experience was incredibly valuable.

Good doctors know that it's not about them, but about patients. And that starts by not assuming that being pre-med means you belong, unvetted, at the bedside.

frankbill said...

Why not have them becomes EMT's and have serve as EMT's for a year? This should give them good per med training.

Anonymous said...

Just a pointless exercise that favors rich kids whose parents know a lot of physicians.

Vamsi Aribindi said...

I think some of the sentiments here betray one's background. Working in an academic medical center (or really, any hospital with a residency program), and being exposed to the world of medicine blinds us to just how difficult it can be for a student from a relatively unconnected family ( the children first generation Chinese or Indian immigrant families, Inner-city African-American and Hispanic children, Rural families) to gain an exposure to our lives and what it means to be a doctor.

I speak from a privileged background- I had a luxury of having several family members to talk to as I grew up about their careers and lives as doctors.

While volunteering or working is all well and good, it doesn't always provide nearly as much of a window into the doctor's role as one might think. The local community hospital (which may be all the student has access to) without a residency program has doctors rounding alone and popping into patients rooms for a few minutes each morning before heading off to the OR or clinic for the rest of the day- where few volunteers have access. Little teaching or commentary sounds out in the halls of these hospitals.

I agree that pelvic exams are probably not a good place for students. But does that mean that no Ob/Gyn can really ever allow a pre-med student to shadow them? I suppose they can let students come in for the interview and then ask them to step out.

Ultimately, while attempts to restrict observers and "shadowers" on the basis of "patients come first!" is perhaps inevitable, the end result will be that those individuals with no relatives in medicine will be at a further disadvantage. And the decline of medicine from being a profession open to anyone with the work ethic to a profession open only to those who have the resources to compete will continue. Multiple studies have shown that patients do better (and medical students learn more) when doctors are diverse in their backgrounds. That will increasingly fall by the wayside- casualties on the basis of "patient welfare".

Skeptical Scalpel said...

First anon, well said.

Frank, I'm not sure everyone can take a year off. Also, becoming an EMT requires taking a course, and it has little relevance to what doctors do.

Second anon, there may be an element of truth to what you said. Some college students may not be able to take 40 hours to shadow a doctor.

Vamsi, good comments as usual. So far no one has addressed the question of whether shadowing is an effective way to learn what doctors do.

Anonymous said...

As a clinical coordinator in a Diagnostic Medical Sonography program, we do have a requirement for shadowing. The main purpose of having them shadow is to see how a sonographer's day goes, and that it is more than just waving a wand or looking at babies. We do have some control over the process and I have never heard of any of our job shadowers actually scanning a patient. Also, our sites will ask permission of the patient to have that person in the room.

Chris Porter MD said...

SS,

While I agree that disclosure was breached, I'd call it poor judgment of the supervising doc, not proof that shadowing is a bad concept.

I absolutely support shadowing. Firstly, because informal shadowing was important to my own career choice, and because I've recently supervised three shadowers - without pre-arrangement on my part. All three fit Vamsi Aribindi's description of the unconnected family. Their schools arranged the shadow.

I introduce them as "future doctor X" and ask the patient if they mind. They don't. I try to show shadowers a balanced view of the joys and unanticipated hassles and sacrifices of doctoring.

While two shadowers have long planned to become docs, the third held family and career flexibility as priorities and was considering PA and nursing school instead - even more so after the shadow. The taxpayer may have just been spared the cost of training a physician.

On the intubation, I'd call the dummy pre-training almost useless. Technically, I doubt the pre-med student was less skilled than a fully-qualified med student intubating for the first time on an anesthesia rotation. I'd call it a breach of trust or contract, but not egregious. Egregious would be leaving the pre-med student alone in the OR to monitor the patient, with no iPhone to entertain them. ;)

CP

Skeptical Scalpel said...

Anon, thanks. I think it is somewhat easier to manage shadowing in your situation.

Chris, I appreciate your perspective. It looks like you are doing it correctly. Your definition of egregious is a good one.

RobertL39 said...

There has to be some way to show pre-med students that they will most definitely NOT be saving the world by becoming doctors. The shine of the calling can fade quickly under the reality of being a data collector. How many of the 50+% of docs (in virtually ALL specialties) surveyed by Medscape who would NOT go into medicine now would have stayed out had they known more about it? Is there any other way to really learn what it is besides shadowing, inadequate though that is? I don't think admitting them to med school and having them find out later is going to help us all very much. Shadowing may have problems, but what else can you suggest to temper the messiah complex?

Emily said...

So it's OK to attach a false title on some college kid so he can get his foot in the exam room door to witness very personal encounters between patient and doctor. What a terrible example to send to these assumed "future doctors" that deception is acceptable if it suits their needs. Never mind that the trusting patient had to be used as a pawn to accomplish this.

Anonymous said...

I have been a fan of this blog for a while now, but have never commented. I am going to start medical school at the end of the month so maybe I can offer you the viewpoint of a pre-med/med student on shadowing.

When I shadowed a general surgeon for several days I arranged it through the clerkship coordinator for the Surgery department through my medical school. I had to fill out paperwork, get immunizations and a TB test. I also had to watch to a video explaining HIPAA. I even had to get an ID badge so I could go into the OR. I went through the department because I do not know any physicians personally, except for my own doctor. I heard from a nurse at the hospital about a physician who let students shadow him regularly, and I reached out to him. I say that to show that some pre-med students are not privileged to have family members and friends to shadow. Also, it obviously varies around the country how hospitals and physicians deal with students who shadow.

As for breaches of privacy and such, I did not have any circumstances like what you described. Personally, I had to get used to just being in the room for the patient interview. I felt very out of place at first, probably because I was as a pre-med. However, I counted it an honor to be a witness to their conversations though. I don't know how I was supposed to know how those types of scenarios would play out as a physician if I had not shadowed.

When I shadowing the attending, I also got to interact with residents and medical students. This was a huge part of what I thought was important from my time shadowing as a pre-med. Being able to talk to them in that setting about their training and how it is for them was huge for me. It really helped me figure out what I needed to do and what would be expected of me when it came time to apply for medical school.

Another thing, and probably what affected me the most about shadowing, was seeing the rawness of medicine. I vividly remember standing outside of a room in the hallway after a code had just been started on a patient in the SICU. I remember seeing the downcast looks on the faces of the nurses and residents after their attempts to resuscitate were for not. I thought about that day for many weeks afterwords. I kept asking myself if I could deal with that situation. I think that it is important for pre-meds to have a similar experience.

Shadowing was one of the main components towards making my decision to go into medicine. Like I said earlier, I did not have any physician friends to talk to, so I greatly appreciated the time that the attendings, residents, and medical students took to show me part of the life of someone in medicine. I have friends, who after shadowing decided not to go to medical school and went another route in the healthcare field. I think that shadowing is very important for students, so please Doctors, keep the door open for us. We greatly appreciate it!

Skeptical Scalpel said...

The three most recent comments above highlight the issues very nicely. If a student shadowed a burned out doc, she might be unduly discouraged. Emily gives us the patient's point of view. The anonymous student had a very positive experience. Take your choice.

webhillizzy said...

As a child, I was privileged to be brought along with an OB friend of the family to the ER on more than one occasion, to see patients while he was on call. I was introduced by my physician friend to the patient as "a student of mine," and I do not suspect I was thought by anyone to be an actual med student during the first few of these visits because I was still in high school and did not look very old. No one ever complained about my presence though of course I do not know how they felt about it inside. Of course I never TOUCHED anyone or anything and stood quietly on the side of the room, observing.

As a patient, I have always encouraged anyone introduced to me as a student to participate fully to the extent of his/her abilities and legal permissions. I feel this is important. The only time I rejected the presence of a medical student was during one of my labors, when they asked if a student could come in at a particular moment and I blew up at the asker... I apologized later though. I actually wasn't against the student coming in, I was just against carrying on any conversation of any kind at that moment, LOL. If someone wanted to bring in a pre-med student to one of my office calls or hospital-based procedures or whatever, I would be fine with that, as long as they were kept to the side.

As a professional (I'm a veterinarian), I enjoy having young students come in to observe. Their questions keep me on my toes!

Anonymous said...

webhillizzy, I'm concerned because you said "as a child" and "OB". One of the reasons people mistrust doctors is because that situation was totally inappropriate. I could repeat what you said and people would go gangbusters. The doctor lied to the patients by saying you were a student and you were not an enrolled medical school student. With all due respect, there are boatloads of violations that could have been leveled at the hospital and the doctor. What doctors refuse to understand (a number of them) is that we are due specifics as to who is in there in our private moments, and not to put it in such a way that we are stuck with someone there. I've had it done to me, and at times it is ok, at others, I have stated not.

What many patients would find offensive is that you didn't state plainly who you were and asked their permission. There are those who don't mind, but that you didn't respect others (including that doctor) says volumes about the medical mindset and why there are so many patients who despise doctors.

I'm stating this as a point of view from us, patients.

Anonymous said...

Chris Porter, do you put what you are doing to the hospital? You are technically lying to the patient if you are saying future doctor X when they are not in medical school. Have you told the hospital and the like you are doing this? You malpractice people? Your HIPAA liaison? Consider how your family would feel when they are vulnerable and then someone lies to them.

Anonymous said...

RobertL39, how about having them do the "scut" work or the computer work? They can read on the internet boatloads of medical students and premed stuff, they don't have to shadow a doctor. They can imitate that without patient EHR access.

I have to admit, I was to have been the doctor of the family. I figured out from reading, the attitude and atmosphere was not for me. There is no excuse or reason that someone can't go through the tons of blogs out there and get a really good idea of what being a doctor is like. Ask questions, good and bad (especially the bad, you are better prepared). Stop watching TV and talk to retired docs, docs in their first 5 years, doctors at 15 years, doctors who work for hospitals, contracted doctors, free lancers. If you can't do that homework and that amount of reading, you shouldn't be a doctor. If you don't network and learn from those before you (which that investigation I just put requires), don't become a doctor. That's what you are going to get your first year, they don't call it trying to drink from a fire hose for nothing.

Most of all, if you can't and a practicing HCP can't or won't, represent yourselves honestly, you are a danger to yourself, the patient, and the MD & potentially the hospital/practice. Ask a risk manager or the HIPAA person after they've recovered from the heart attack. It would take one thing to go wrong and a lawsuit to find that someone was in there for to the doc & hospital to be left high and dry.

Read Joan Rivers case and who was in the room ...

RobertL39 said...

We've got two different things going here: 1) Whether shadowing can be helpful and 2) How to do shadowing correctly and ethically. From my experience shadowing and being shadowed, and that of the almost-medical student above, I think it's helpful. Do some people make insensitive, stupid decisions? So what else is new? Is the process itself helpful? I think so. I don't think reading about medicine gives one the same flavor as being in the trenches. Isn't the question more whether one wants to take care of people in that environment, rather than how other people describe the environment in writing? If it looks bad from reading about it, don't do it. If it still looks good, shadow someone and see if it works for you. I think you have to be there to really understand.

Skeptical Scalpel said...

All 5 new comments are appreciated. I think that shadowing could be misleading. I doubt that most docs would show a student the negative aspects of medicine. That's why I would welcome an in-depth study. Also, the patients' position needs to be considered.

artiger said...

I take exception with one of the above comments about going "through the tons of blogs out there and get a really good idea of what being a doctor is like.". Its foolish to think that would be true for being a physician, a nurse, an astronaut, professional athlete, soldier, or president, or anything else. I can't believe someone actually wrote that.

Be that as it may, shadowing has to take a back seat to patient wishes and privacy. I recall back in my premed days, when one of my best friend's father was the solo surgeon in my rural town. He was nice enough to let me shadow him, but I was also employed as an orderly at the hospital, so I was in the building in an official capacity. I was quite surprised at how people were more than willing to allow me to be present during procedures and exams. Many of them were people I knew. Of course, we also asked permission, and if there was any problem I simply stayed away.

But to the point...it was an extremely positive thing for me in realizing that I wanted to be a surgeon, and specifically, a general surgeon in a small town, which is not exactly a popular choice these days. Had I not had that exposure early on, I might very well have taken a different career path.

But again, to be clear, patient preference trumps all. It doesn't hurt to ask though. You might be surprised how many patients are willing to help contribute to the future of health care.

Skeptical Scalpel said...

"I take exception with one of the above comments about going 'through the tons of blogs out there and get a really good idea of what being a doctor is like.' Its foolish to think that would be true for being a physician, a nurse, an astronaut, professional athlete, soldier, or president, or anything else. I can't believe someone actually wrote that."

I have to disagree with you on this. I'm not sure anyone is routinely shadowing "an astronaut, professional athlete, soldier, or president." Yet there are many people aspiring to all of those positions.

I think you just proved my point.

artiger said...

Respectfully, I wasn't trying to disprove your point. It's one thing to aspire to be something, but knowing what it's like to be that something is another. And reading a bunch of blogs or books isn't going to let you know what it's really like. If that were the case, medical students could just read without seeing patients.

I aspire to be a chef. I watch Geoffrey Zakarian, Bobby Flay, and a host of others all the time, and read a lot of their blogs. I don't think I'm getting a real idea of their lives just by what I see on TV or read.

I simply had a good experience with shadowing, but I certainly see the negatives.

Anonymous said...

If you want to see what being a doctor is like, watch old reruns of ER. The procedures are fairly accurate as are the drugs and their dosages.

I agree with "anon" that said it is nothing but "a pointless exercise that favors rich kids. . ."

I would have learned WAY more if somebody had spoken to me about the REAL business of medicine. But, even that would not deter those of means--many who graduate with little to no debt.

But, again, I'm REALLY jaded.

artiger said...

Anon above, I hope that was a joke (about watching old reruns of ER).

Skeptical Scalpel said...

I think I may have said this somewhere in another post or comment, but it bears repeating. I watched exactly one episode of "ER." The ED doc had a woman in labor and called upstairs to the delivery room for forceps. That was it for me.

artiger said...

Scalpel, that means you've watched 0.5 more episodes than I have.

Anonymous said...

I don't know, I find a lot of blogs to be pretty dead on. What is the biggest thing that docs need to know is out there: how much of your life is a being a clerk; how much of your life is dealing with people who will nail you if don't give them the narcotic of choice; getting up at 5 am and leaving at 7 pm; missing family adventures; medical school debt for some; having people ask you medical questions about hemorrhoids because you are an MD whether you are a pediatrician or in geriatrics; the amount of bureaucracy in medicine. That's just for starters.

There is a lot that someone can learn. I normally don't admit to this but yes I have a "background", I'm not an MD, but I've shocked more than one doc into admitting I have a pretty good clue of what goes on. There are enough docs around who are kind enough to help share and do it honestly. Take advantage of it. I have, and have been blessed by it. Thank you to all those for the honest and accurate education. I'm grateful.

PS This includes you Skep ...

Skeptical Scalpel said...

Artiger, I'm surprised I outlasted you.

Anon, thanks for commenting.

Anonymous said...

I don't know about human medicine, but in veterinary medicine where I work shadowing is not required but it is highly recommended. I'm an LVT and the doctor I worked with was very open to shadowing. The students were introduced to clients as an undergraduate student interested in vet med and were not allowed to do anything but observe. On one memorable occasion the Dr. had two students shadowing her for morning appointments, the first appointment was for anal gland expression and the second appointment was for an anal gland abscess, Both students left that day with a comment along the lines of "Thank you for giving me the chance to realize this is not what I want to do before I spent 250k on Vet School."

Skeptical Scalpel said...

That's a good story. The other thing about shadowing a veterinarian is that the animals are unlikely to ask who the stranger in the room is or to complain.

artiger said...

The vet shadowing story proves my point...does anyone think you can get a full appreciation of anal gland problems just by reading a bunch of blogs?

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warmsocks said...

Shadowing is sometimes called observing, and other fields do require it. Students applying to DPT school must document observation hours in a variety of physical therapy settings (inpatient, outpatient clinic, other ie nursing, home health, etc). The minimum I've seen is 80. Most programs require at least 120, and strongly recommend well over 400 observation hours. Also, some teaching programs require 80 observation hours of applicants. Our local EMT program requires observation hours before students are admitted to the program. Engineers don't require shadowing, but engineering students are required to do an internship. Those are the fields I know for sure about.

As for patients having a say, my daughter's rheumatologist once introduced someone shadowing her. He silently stood by the door and observed. The dr did the exam as normal, and occasionally explained things to the shadow. I suppose we could have objected to the shadow's presence, but we would love to see more rheumatologists so if someone applying to med school wanted to know more about the field, we thought it was great. OTOH, we would definitely object to someone shadowing ob/gyn.

In medicine, it seems like there are better ways to get a feel for the field than shadowing. My niece is pre-med and works as a scribe for her local ER. After three years she is the program supervisor, and has gotten a fairly good idea of what an ER doc's work is like -- much more realistically than if she just followed someone around for a week.

Skeptical Scalpel said...

Warmsocks, thank you for the information. Pt is a liittle different than most specialties of medicine. PT is about activities with at least some clothes on. EMT is interesting. I guess people who are injured or acutely sick are less inclined to wonder who is lurking in the background. You are right about being a scribe. I have mixed feelings about it for the doctor, but it is good for the scribe who is interested in medicine or already in med school.

Anonymous said...

I worked as a hospital orderly during the summers of 2 pre med years and also between the non clinical med school years.
Initially we were required to complete a 6 week training course on basic nursing skills etc.
We worked under an RN and could place foley catheters in non complicated patients. There was exposure to all hospital departments including the morgue as we were the ones who washed the deceased and transported them to the morgue.
Among other skills I gave bedbaths,enemas,fed patients ,cleaned up the mess and overall had a blast!
I got to know the patient's feelings and fears and learned much from the RNs and other health professionals.It was from a much different perspective than as an MD....
The experience made me a better person and in the end a very compassionate physician.
There were a few other fellows who did the same but realized early on they were not "cut out" for the profession.

I think this should would be a much better way of exposing a pre med student to the medical field.
If I were on the admission committee I would give any candidate with such experience a bonus point!
BTW I became a urologist....

Skeptical Scalpel said...

Anonymous, I also worked as an orderly during the summer between two of my college years. I agree it was a good experience and was much better than shadowing. I don't think the position of orderly even exist any longer. To be a patient care technician, one must take a course. It may be more difficult to obtain a position similar to what we did is orderlies.

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