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Spandorfer J, Pohl C, Nasca T, Rattner SL, eds. Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge: Cambridge University Press; 2010.

Thomas Jefferson University

Video: Commitment to Honesty with Patients | Commentaries

A Medical Student Perspective

As a fourth year medical student, Dr. Wilfond's below essay struck a chord. He makes a compelling case for full and complete disclosure by a student doing a first-time procedure. Then why, I wonder, when I found myself in a similar situation, was "acting ethically" neither clear nor easy?

During my recent Emergency Medicine rotation I saw a middle-aged man with AIDS and severe neck pain. When I presented to my preceptor, he responded, "So you'll do the LP." We briefly discussed that this would be my first time doing the procedure, although I had watched plenty. He assured me that he would lead me through it. I reflexively took his offer as a sign that I was worthy to do the procedure. The desire for approval from respected preceptors goes beyond formal grading.

When I explained to the patient that I would be doing the procedure with my doctor supervisor close by, he laughed: "Oh yeah, last time the rookie couldn't get it, but neither could any of the old doctors." Clearly I was in a situation with an informed patient and a thoughtful preceptor, yet I still chose not to tell this patient it was my "first time." He seemed to understand that I was inexperienced, but if I told him directly that this was my first time, would he still consent to the procedure? During our conversation, I was conscious of my own tug between wanting to be honest in combination with a near-desperate desire to try the LP. By making my inexperience explicit, I worried I would not only make the patient more nervous, but also risk having this learning opportunity taken away.

Should a patient be given the opportunity to opt in or out of having a medical student doing a procedure for the first time? We typically learn using patients until someone objects. Hospital employees or physician's family members often avoid care by a student. Conversely, families who do not speak English are rarely informed or empowered enough to opt out of student care. When students like Rebecca are put in the awkward position of being called "Student Doctor,"our participation verges on deception.

During my clinical rotations, I became aware of a perceived race to learn procedures. Learning how to do a paracentesis seemed like less of a learned skill and more of a badge of honor. On rotations lacking hands-on practice with procedures, I feared I was "falling behind"my classmates. In reality, we all need to learn procedures on some patients in order to perform them competently on future patients. As discussed below, the potential risks and benefits justifies a medical student's participation in some cases while not in others.

In the end, I attempted but did not get the LP. The attending guided me until it was time for his hands to take over. I felt indebted to the patient for allowing me this chance to learn. In return, I spent time giving careful answers to his questions and smuggled graham crackers from the nurses' stations. I hope that despite a few extra pokes in his back, his overall experience was enhanced by my participation. As medical students, we continually struggle to find our role; what do we do for patients, and not just to patients. While we lack experience, we should not underestimate what we can offer: time, compassion and a fresh perspective. Ultimately, honest communication may go farther to help patients than whether or not we "get the LP."

Sarah Bergman Lewis
University of Washington School of Medicine