Jennifer Chevinsky, B.S.

Conversation around the ethics of medical student treatment – or mistreatment – has changed greatly over the past 50 years. From hazing to ‘pimping’ – overnights to business hours – ‘see one, do one, teach one’ to facilitated and guided learning. Literature continues to discuss the moral erosion of students as they progress through medical school and go on to further training. The hierarchical structures and the domains of influence (especially relating to grading policies) have been illuminated. What are ways that you, the healthcare professional, can best and most ethically incorporate medical students into clinical practice?

Starting on my third-year medical school rotations, I have been given an amazing and humbling opportunity to interview patients, perform physical examinations, and participate on a medical team. In my time thus far on in-patient and out-patient services, I have noticed patterns that are both helpful and harmful to the process of learning as well as the provision of optimal health care. Below I have included five tips for medical professionals to guide medical learning and prevent moral decline, based on my experience thus far as a third year medical student.

5 Tips to Guide Medical Learning and Prevent Moral Decline:

1. Provide medical students with appropriate autonomy and responsibility

Although practitioners may have different approaches based on their practice – in-patient or out-patient, primary care or surgery – practitioners should set up clear expectations of what the role of the medical student will be, maximizing and challenging his abilities. This should not be a time strictly for practitioner shadowing. Students may differ in their comfort level to perform certain parts of the clinical encounter, but by their third year they should be capable of taking a full history and performing a full physical examination. The medical student should not be filing paperwork or calling patients in from the waiting room, their role should be fitting to their skill level. Similarly, they should not be asked to go beyond their scope, writing out prescription or dictating notes. Typically, after watching the student perform the skills of history taking and performing a physical examination once, attendings should send students to see patients on their own. Students can then present their patients to the attending and/or the clinical team. Of course, it will be important to balance the student autonomy and responsibility with challenges to time, recognizing that patient care ought not suffer because of the learning process.

1. Ask questions to check understanding of important principles and concepts

By listening to the student’s presentation, attendings can gain insight into the student’s thought process. When you see a potential gap in knowledge, based on questions that were not asked during the history or important parts that were left out of the physical exam, ask the student about it. Did that aspect slip his mind? Did he intentionally leave it out, thinking it wasn’t relevant? Did he not even consider that line of questioning? Depending on the reason, the attending can provide follow-up questions or help fill in the gaps. The attending should only ask the student to look the answer up online or in a textbook if there is ample time to guide the search and discuss the results. Alternatively, if the student did collect all of the pertinent information, ask questions to make sure that his line of thinking was appropriate and to reinforce important concepts. Does he know why it might be important that the patient with muscle weakness that is worse as the day goes on also developed double vision? This line of pertinent questioning is different and more helpful than random quizzing of minutia and it attempts to decrease humiliation and embarrassment. Finally, don’t forget to ask the student if he has any questions about what he has seen or performed that day.

1. Treat medical students as important members of the clinical team

In order to increase efficiency, build the medical student into the clinical team. If the medical student is considered an ‘add-on,’ then there will be no surprises when the team becomes behind schedule. Instead, come up with a plan to maximize resources. For instance, if the medical student takes a full history during the time that the physician is seeing another patient, not only could this provide important information, it could also save time for the team. Medical students can be the window into another realm of the patient’s persona; they can be your warm up act, preparing your patient for the conversation to come. Sometimes patients feel less threatened by medical students and are more willing to discuss information or concerns that they otherwise might not have raised. Medical students typically have more time than other members of the clinical team; they can build rapport with patients and improve patients’ satisfaction with the visit. The team or attending should follow-up with the patient, using the student’s notes to guide the encounter and expand where necessary. Having the student’s notes as a basis can help inform the team of the patient’s main concerns. Figuring out a clear idea of how the medical student can fit into your clinical team will help address the challenges of time and can aid in providing high quality medical care.

1. Model good relationships with team members

It is true that the most obvious area of learning for third-year medial students relates to clinical care of patients, but a very important and often unrecognized part of patient care is team dynamics. This is the first time that most medical students are exposed to working in a medical team. Students become discouraged when they see individuals disrespecting team-members, whether in the form of disregarding the importance of their time or effort, or outright bad-mouthing their skills or approach. Medicine is becoming more and more a team endeavor and the more that attendings can exhibit or discuss teamwork with students, the better prepared the students will be in the future. Talk with students about the roles of physician assistants, nurse practitioners, medical technicians, etc., and teach them the proper way to interact with all types of medical professionals.

1. Treat patients with respect at all times

Although this should go without saying, I think it is certainly important enough to include in the list. It seems too easy for practitioners to make a comment about ‘the heroin addict’ or ‘the crazy.’ Humor can be great to diffuse tension, but it should not be at the expense of a patient’s dignity. Although years of practice might turn a medical practitioner into a cynic, he should be very careful about letting that affect the way he talks with or about patients. I mention this despite the fact that practitioners have heard this before and know that it is not ‘technically appropriate’ because this kind of talk still occurs in every hospital. It can even be a sign of acceptance into ‘the inner circle,’ welcoming the student into the reality of medicine. Regardless of the reason, such comments are inappropriate and have a negative ripple effect on the patient, the clinical team, and the medical student. By partaking in such conversation, the practitioner risks losing respect as a medical professional. Instead, if the practitioner thinks there are real moral, ethical, or clinical concerns, he should discuss it with the student in a nonjudgmental manner.

By following these ‘5 Tips to Guide Medical Learning and Prevent Moral Decline,’

1. Provide medical students with appropriate autonomy and responsibility
2. Ask questions to check understanding of important principles and concepts
3. Treat medical students as important members of the clinical team
4. Model good relationships with team members
5. Treat patients with respect at all times

you can create an atmosphere where medical students are further encouraged about their journey into the medical field, addressing the moral decline that students have experienced in the past years. Most universities and hospital systems have a mechanism for students to report violations of professionalism, but these mechanisms are often underused due in some part to fear of retaliation. If you are a practitioner who works with medical students, you can make the change that creates a better physician for future generations.