Wednesday, June 29, 2011

Being treated by trainees

During my OB/GYN rotation in med school, I attended an outpatient clinic that was your typical mix of obstetrics and gyn patients. The model of the clinic was that the med students would see the patients first, then present to the resident who would do most of the work, and the lone attending would see the patient for about sixty seconds.

One morning in clinic, we had a patient with some chronic gyn issues (can't remember what) but she felt she'd "had enough" of telling her story over and over, so she refused to be seen by a student. The nurse who roomed her warned that this would result in a longer wait, but she was OK with that.

None of us had good feelings toward this woman we never met. In any case, she went to the back of the queue and stayed there. An hour and a half later, she still hadn't been seen by anyone... and only got seen because the nurse came back out and yelled at us.

It's hard, when you're in training, not to get angry at patients who don't want to be seen by a student or resident. If you go to a training hospital or clinic, I feel like you're obligated to allow it.

I've been on the other side, so I sympathize. When my daughter had a fever and was really irritable, I didn't enjoy holding her down twice so the resident could look in her ears too. I've gotten pelvic exams from med students and I've allowed an intern in the ER to stitch up my laceration while she got step by step instructions from an attending. So I'm not a hypocrite.

After all, how else are the going to learn? I'd rather be treated by a less competent supervised trainee than an incompetent unsupervised attending.

What do you think about patients who refuse to be seen/treated by trainees?


  1. On heme-onc elective, there was a patient who didn't want to be seen by me, and the attending gave him a really hard time about it. To the point of verbal abuse. I'd really rather not see patients who aren't ok with being seen by me. It's really not going to end well.

    I think my personal ok-ness with seeing med students really depends on why I'm there. Since I am currently a med student, I think it would be kind of (actually really) awkward to get a pelvic exam by another med student, and since there are a bunch of fellows in my PhD program, it would also be awkward if one of my classmates did it. After my Ob/Gyn rotation I swore I would never allow an intern to delivery my baby, but that was mostly because one of the interns told me that fewer of her patients ripped now than they did at the beginning of the year. Also, they were such bitches, I can't say that wasn't a factor either.

  2. Well I've tried posting this a few times now and blogspot keeps eating it.

    There might be a perfectly good reason why they do not want to be seen by students.

    I refuse to get seen by medical students. I have a chronic medical condition where only 1 in 100,000 females have (more common among men). In 2002, I went to the obgyn because I was pregnant and I was treated so poorly by the student and their attending and had my disorder fun of so severely that I developed a medical phobia. Wasn't until I developed epilepsy and was having 100 seizures a week that I decided to try to see doctors again.

    Needless to say, I am very selective about the doctors I see.

  3. Well, I've never had the opportunity, but i probably wouldn't want to be seen.

    I actually just wrote about this, but as a pharmacy student, I also had an OB/GYN rotation (we're only there for a month). For us, we basically followed a resident around all day on clinic days and helped them with medication stuff.

    There are some days in pharmacy school when you wish you went to medical school. Not a single day that month did I ever wish that. At first I would try to excuse myself during exams, but the resident wouldn't have it. I was asked if I wanted to give a pelvic exam to a lady who had "an interesting case" (like I would know, we don't learn that), asked if I wanted to assist in a birth, asked to perform several breast exams, etc. Never was I identified to the patient as a pharmacy student (and if I were the patient, I would want to know if a pharmacist was all up in my business).

    The first time such a thing was asked, I blurted out, "I'm pharmacy!!" and left the room, lol. Probably the wrong response, but I got a lecture from the resident about being part of the healthcare team and using every opportunity to learn and make the most out of my time there, etc. I honestly think the resident was trying to be NICE and include me, but I felt bad for the patients for some strange future drug dealer chick to be hanging out while they were up in stirrups.

    Anyway, point being I don't want some law student or high school sophomore examining me, so I'd probably decline. :-)

  4. I'm a psych NP and always appreciated (and felt a little sorry for) the patients who let me poodle around in their psyches when I was first learning to do diagnostic interviews. I consider being nice to students obligatory pay-back, so I have great sympathy for med and other students.

    My patience came very close to running out, though, when, with a newly diagnosed Stage III breast CA, I went in for a mastectomy. After the third student came in and asked to examine me, I told her that I was going to start charging admission unless within 20 minutes everyone who wanted to cop a feel had gathered in my room. I told her that everyone could have a turn feeling me up but that I would not allow anyone else in after that.

    For the emotional state I was in, I think I showed admirable restraint.

  5. *I'm* cool with being seen by students, but I'll admit - my brother is intellectually disabled, and sometimes med students don't have the first clue how to talk to him, so my whole family finally just asked that med students not see him (he was hospitalized for an unrelated illness).

    So I know I should be cool with it when patients refuse to be seen by medical students, but occasionally my feelings get hurt. I wish I could have an emotion-ectomy.

    This is a great topic, Fizzy.

  6. Depends on what it is. I taught the medical students who are now in clinic. For the most part I really don't care if they are there, but for certain urology things I'd rather not have them. I know they need to learn how to give exams but I'm not all that comfortable having my gross anatomy lab partner checking out my junk. I know when I come into the clinic it's going to be annoying for the patients, just like it has been for me when I have to explain everything 3 times. You have to learn somewhere and sadly most people don't realize that. Great topic.

  7. OMDG: Agreed, I wouldn't have wanted to be treated by a trainee that I'd have to work with. Also, re the ob interns, when I was in the hospital overnight in 2nd trimester being observed for premature contractions, an intern came in and said they were going to break my water soon. That certainly soured me on OB interns. That's why I delivered at a hospital with no residents.

    Family Aerospace: That's terrible, I'm sorry to hear you had such a bad experience. But I also think some med students are more compassionate and have way more time to spend with you than an attending. I've had plenty of attendings who soured me on doctors.

    Amanda: I didn't know pharm students saw patients. I don't think I'd mind a non-medical student, depending on what my medical issue was. Probably not a pelvic or breast exam.

    Knot Tying: Sheesh, I'm sorry you had to deal with that with newly diagnosed cancer. They should have been more sensitive.

  8. I used to live in a town with a BIG teaching hospital. One summer I got the fun of being a good "teaching case" for derm. Of course it was DERM, didn't involve anything intimate, and I had nothing else to do that day.
    The first time someone came into the room I was asked if a med student could see me. I said "Yes." That med student was a little nervous, but did a good job and then left to confer with the resident, following which, the resident asked if I could be seen by several more students. As I had all the time in the world that day (and the hospital was air conditioned and had a good selection of magazines) I said, "Yes".
    After much of this the "real" dermatologist was brought in and after an exam asked if he could bring the whole bunch of students and residents in for a quick "diagnostic seminar"...I said, "Yes."
    I had presented as something quite dire, but I actually wasn't and the senior MD wanted everyone else to learn to differentiate the difference between my presentation and "the real thing". He finished by saying, "You'll be seeing this alot this summer and I want you to see a really good example of it. We will not finish off by doing a confirming blood test, which in this case should come back negative. Are there any questions?"
    All together is was a really interesting experience, lasting about 2.5 hours rather than 15 minutes, but if they all learned something out of it, great!
    If it had been gyn, I'm not sure that I would have been so accomodating.

  9. Coming from the front desk point of view, it drives me NUTS. You are coming to a UNIVERISTY MEDICAL CENTER. A UNIVERISTY. One would think that it's full of students...and how do you think that they learn to become doctors? It's not like they let students do brain surgery around here or anything like that, but they may need to come in and ask you a few questions. It's not the end of the world (despite what some people may make you think with their over-the-top reactions). Personally, I don't have a problem with it - when I had surgery here, I told them to bring in as many students or residents to watch as they could fit in the room. Call me your guinnea pig :)

  10. Well, in South Africa the training hospitals are all public hospitals; so those who can afford medical aid or their bills generally don't have to be worried about being treated by "us".
    In general, the patients we deal with are just too happy to be seen by someone - queues are very long at state hospitals - that they don't complain, and most of them do know from the beginning that they are at a training hospital.
    I had my first incident with a patient wanting a procedure to be done by the "real" doctor. He had polymyositis and we had been trying to get IV-access for hours - 21 times, to be exact. He couldn't swallow anymore, so we decided to place a Nasogastric tube. I still needed another one for my logbook so I was going to do it, but he indicated that he'd rather I didn't.
    I don't blame him. He was 26, tired, and scared.
    It is just one of those things that happens from time to time. If if happened unnecessarily I would not be happy, but in this case not so much.

  11. Patients in general have an ethical obligation to allow trainees to participate in their care. ALL patients benefit from the training that their doctors/NPs/PAs/RNs/etc received. When patients can refuse to see trainees, they get that experience at the expense of other patients who are less educated or less saavy about the medical system. Because all patients benefit from medical training, all patients should share the costs of medical training as well.

  12. my last day of Family practice residency, a woman came in to get her prenatal checkup - she was due that week i believe. she didnt want a 'student' touching her as she and her chiropractic (!) husband kept saying. they barely allowed me to take her blood pressure. so i got the incredulous attending from another clinic (since it was my last month i was doing my own clinics with the barest of oversight), and i stayed in the room as he did the PV to check for dilatation.

    afterwards she said cheerily, "i'm sure you'll be a great doctor when you are done - when is that?"

    "tomorrow" i replied tartly before leaving.

  13. Fizzy - The treatment from that medical student caused me to nearly die on several occasions because of that phobia. The fact that the attending wasn't in there often, didn't help or hurt. This went on and off for months. Have you ever seen an adult who used to only be scared of needles suddenly get so worked up that you couldn't even say the word hospital without the person breaking into tears? It took 5 years before I could visit a doctor and 6 years before I could enter a hospital, even as a visitor. I still have nightmares and it was mostly the student although the attending was certainly a jerk. I actually returned to the medical school where I was traumatized and told the first year students my experience. An attending I am friends with told me how brave I was and how I didn't look nervous at all. Ironically, I decided to go premed once the phobia became under control, primary care for people with my rare disorder is high on my list.

    bjackrian - So, are you saying that it is perfectly ok for medical students and attendings to abuse/traumatize patients (who had no say in the matter) to the point where the patients are reluctant to see doctors ever again? It's one thing to be a trainee. It's another thing to mentally abuse the people you are supposed to be helping. The students and doctors have an ethical responsibility to do no harm or at least do as little harm as possible.

  14. I work in a university setting, so I'm accustomed to dealing with students, residents, etc. Good point: the newer folks ask you more questions and will even come back to see what the attending said. Downside: they leave just as you've broken them in.

    Side note: My spouse works in ENT. Guess who gets to fill in for exams if they have an odd number of students? She also gets to tell the story of how her thyroid cancer was discovered - over and over and over again. :)

  15. For chronic issues, patients have seen enough doctors and been through the wringer to where their wishes should be respected. It's kind of uncomfortable for me to read in the comments the obvious disgust medical professionals have for such (selfish) patients.

    I take issue with the idea that a patient has an ethical obligation to let students maul them. The larger ethical burden is to ensure students don't interfere with the patient's care in a specific encounter and, if a patient is uncomfortable, that should be the end of it.

    I have yet to say no to students, but I can see it becoming an issue in the future.

    Years and years ago when doctors were busy missing the SAI diagnosis, they thought I had chronic fatigue. The doc sent a parade of interns through my room to stare at me. It was quite strange as I couldn't fathom how such awkward staring helped anyone learn anything. Talk about feeling like an animal at the zoo!

    On the flip side, my previous pulmonologist used to send the parade of interns in so they could see that educated asthma patients really do exist. She also had me talk to pharm reps too. That felt more helpful, although I'm not sure it really was.


  16. Throughout nursing school, I only had one patient who did not want me to take care of them. I actually had quite a few patients who seemed positively thrilled to be part of the teaching process - even if I had to stick them twice or take a little longer putting in a foley. I'd occasionally run into a patient who seemed skeptical. ("Have you done this before? Are you old enough to be doing this?") A lot of winning them over was just appearing confident and putting on a ridiculously cheery face.

    I guess it could be different for medical students. It seems like it would be hard to build up confidence - on a lot of units that I worked on, even the aids wouldn't give the medical students the time of day.

  17. When I was undergoing my midwifery training, which was very similar to the med student/resident/ attending model, I had the opportunity to work with patients who were quite accommodating. I certainly understood if someone didn't want me performing my very first Pap on them and never felt anyone was obligated to allow me to be part of their care. If anything, what I felt was gratitude for being allowed into someone's personal space (I hadn't done anything to earn that trust) and I believe the women I cared for appreciated that. They knew I was a student because my name tag clearly said "Student Midwife". In contrast, I can't count how many times I've been cared for by a student doctor who is uncomfortable admitting that they aren't done with their training. I think part of the problem is that the hierarchy within medical training puts students at a disadvantage because even other people on the team don't respect them. Do we really think patients don't sense that or learn it somehow? Personally, I don't have an issue w/ students being a part of my care because I've been there and I know most have good intentions. But can you blame a person for not wanting the supposed "scut monkey" to perform procedures that the patient may find intrusive or scary? I can't.

  18. As somebody with a 14 year history of chronic subglottic tracheal stenosis and tracheomalacia, I have to say that it's very hard to have patience with a student who is not aware of the condition, especially when my airway is obstructed or in the process of collapsing. I once described my condition to a student who asked me which ear the problem was in. Hello, 'tracheal' stenosis should have been a clue!! Then another student felt that I was becoming 'agitated' and proceeded to inject me with a large dose of diazepam, without consent and most certainly against my will. And unsurprisingly, my breathing got a hell of a lot worse.

    I don't believe that you should tar all students with the same brush, I have in my time met several very excellent medical students. But see it from the patient's point of view. If you have a life threatening illness, you need somebody to tell you what IS wrong, not what they 'er, think might be wrong'. Do you see what I mean? It's psychological and not really based in reality, but if it helps somebody cope with what is in fact a might burden, then surely they should be accommodated, without any kind of grumbling from students.

    To a student, a patient is an 'interesting case, with good potential for a learning opportunity'. To a patient, it is their LIFE. They only get one of those. Students get to see many more patients.

  19. TSS: I sympathize with your POV and understand your frustration. But look at it this way, if everyone with your condition refuses to be seen by trainees, who will be competent to treat you in 30 years, when the current physicians are retired?

  20. Dr. Fizzy: RE your response to TSS, it's not an all or nothing situation. Students can observe, they can follow the course of care, they don't have to lay hands on every single patient without exception to learn. They could even respectfully invite the patient to come speak about their medical condition.

    If students are letting other avenues of information gathering/learning pass them by simply because a patient didn't want to be a guinea pig, well, that is the real reason there will be a problem in 30 years.

    As we have seen in the comments, students are over stepping. I myself had several not-yet-doctors (residents??) botch a nerve block for surgery. It wore off in the middle of surgery (can you imagine?). They knew they screwed up but they hid it and I didn't call them on it (I was pretty doped up).

    At what point do we start trying to change the system so everyone wins? When do we acknowledge that there is a distinct lack of respect for patients? That the potential for abuse exists?


  21. POP -- Oh good god, really? You think that shadowing some doctor is some sort of substitute for actually taking the patient history yourself and doing an exam? Got help us when those students become residents. SOME students overstep, and guess what, so do some attendings. I also don't see where you're getting this general lack of respect that apparently all doctors have for patients. What's up with that? What exactly about the system do you think needs to change?

  22. POP: It's a tricky situation. In the case of the nerve block you mentioned, there's really no way to be able to do that well without practicing on a real person. It's not ideal and it subjects people with chronic medical conditions to perhaps an unfair amount of "being practiced on." But they should *always* be carefully supervised, which I think would have prevented that complication you mentioned.

    Obviously, it's important to always be respectful and I maintain that a good med student can actually benefit patients. When I was a med student, I had a LOT of patients who were profusely grateful to me for taking time to explain things to them and spend time with them when the attending couldn't. I still remember an L&D patient I had as a med student, whose hand I held through her D+C, and she told me she didn't know what she would have done without me there.

  23. I once had a query borderline personality on an internal med unit refuse to be seen by residents and interns on particular days (inconsistent). At one point she blurted out "NO INTERNS!" when the resident went to see the patient in the far side of the room. The staff doc handled it by saying that he works on a team that has residents and students, and nurse practitioners, and pharmacists, and all the rest of it... and it was fine if she didn't want to be seen by them, but she would be transferred to another doctor who didn't work this way and she would no longer be followed by our service. She relented.

    I've had various other patients say they didn't want a student, and I've never had a problem with it. On the flip side, I've had patients who were a little close to my bubble, and they said to stay even when I offered to leave. A few patients here and there isn't going to make a difference, but if the prevailing attitude amongst a population is that they want "the best care" and only fully trained staff docs, that population is going to end up with some crappy staff docs..

  24. This is a really interesting discussion that raises some excellent points. Learning through direct patient encounters is an essential part of medical training, and I think that patients do have an obligation to contribute to training by allowing themselves to be interviewed/examined when appropriate. But, trainees need to be respectful of and courteous to patients so that patients don't feel uncomfortable or unsafe during the encounter. And attendings need to model appropriate behaviour as well. A number of times I've been asked to examine patients who are clearly in an emotionally vulnerable state (e.g. new terminal cancer diagnosis), and I think that this is unnecessary and inappropriate. To me, it's all about striking a good balance between learning and respect for patients.

  25. I don't personally have a problem with it, but then medical treatment isn't something I have to seek out very often. If it were, I might be tired of being seen by multiple people at each visit but I would like to think not.

  26. Old MD: Just like some students over step, some patients don't want to be stepped on. If you (general you, not you personally) don't get the learning experience you need, you have to find another way.

    The great thing is, most patients do accommodate students. I have, but I certainly want the option to not be the guinea pig without it resulting in anonymous complaints across the internet. I don't owe anyone my life.

    Also, going by your argument, you shouldn't be saying no to those OB/GYN interns. You're depriving doctors of a learning experience. Do I have to be a doctor to control who can touch my body?

    As for what I want to see change? I think about it a lot. I don't have a pat answer, although I do have many ideas.


  27. I work at a University teaching hospital, and am all for letting med students see me. However, they get one shot. During my pregnancy, the 3rd year med student tried to walk the 1st year med student through a Pap, and after 2 tries, I had the attending step in. Also, I had a BRAND SPANKING NEW R1 deliver my daughter, and through the attending's own admission, delivered the shoulders too quickly, and I had a Stage III lac that almost had to go to the OR to repair. Now I had a strict Chief Resident/Attending-only policy for complicated procedures or childbirth. I understand this is the only way they can learn, but if it's going to adversely affect my health, no way jose.

  28. As a nursing student, I've only ever had a few patients tell me they don't want me touching them. I say who really cares? Being sick is scary, there'll be someone else who doesn't care if you practice on them, but people are distressed and I can totally understand wanting someone with a little bit of experience looking after you.

    As someone who's been informed they need a laparoscopy that could possibly turn into a more serious surgery with the consultant, who has been practicing for longer than I've been alive, informing me that there's a 20% chance that she wont get everything, I sure as shit don't want someone digging around my organs for their first time ever. A lot of the discussion above doesn't really show a lot of compassion for patients. I think Solitary Diner put it best. 98% of patients are more than happy to have a student and will tell you more than you ever wanted to know about what's wrong with them, so why get annoyed at the 2% that are frightened and feeling vulnerable?

  29. POP -- The interns get to do deliveries completely unsupervised, which is probably what leads to this situaion. I'd actually rather have a med student in that case since there's someone there micromanaging the process. Do you like fecal incontinence or chronic perineal pain? It's like telling someone they owe it to society to let the intern botch a surgery. Nobody would ever say that.

  30. KT: It's fine for 2% of patients to refuse, the problem is if ALL patients did that. It's OK for some patients to refuse as long as the rest of us are biting the bullet. That annoys me for the same reason that people who don't vaccinate their kids annoys me... they can only get away with it because the rest of us vaccinate.

    I do feel like extra sensitivity should be used with patients who have, say, a new diagnosis of cancer. And the patient's permission should be obtained before marching large number of students in or something unusual like that. I do think attendings may forget they're dealing with people when there's some rare diagnosis.

    I think if you're a med student though, it's very understandable not to want to be treated by other students you know for a sensitive situation. I think there would be few women who would be OK with their friend doing a pelvic exam on them. It's pretty rare that this situation comes up though.

  31. You may disagree with me, but I think that the patient should make decisions about their own care. (without being penalized by waiting longer than others, being verbally abused, etc...)

    1. Should doctors and their families be exempt from being treated by students? Its happening. Just not talked about much. And why shouldn't they? If I wanted a haircut I would want to know how much experience the person had with hair styling before I submit my tresses to their sissors!

    2. In my professional training, I have always respected the needs of the client and would make efforts to respect requests for a more experienced practitioner. Or a male practitioner. Whatever we could accommodate, I tried to do.

    3. My body, my care. I personally have never declined to have a student see me or take a history. I do think a lot is lost when the student presents my history to a specialist (out of the treatment room), who then comes in and makes a quick evaluation based on what the student thought was most important.

    If students must take a history, I firmly believe that the history needs to be presented to the attending in front of the patient so that any errors can be caught outright.

    4. As for physicians refusing to have other students work on them, I'm not sure you can have it both ways. Either the patient has a choice, or they don't. There should not be a different level of autonomy for physician-patients.

    (and yes, I know it sucks to be treated by people you know, it's happened to me and I've dealt with it).

    Bottom line for me: Medical students do not have entitlement to assess or treat any patient they wish to see. To think otherwise is paternalistic and arrogant.

    Patients need to own their bodies and own their choices without fear of reprisal.

    I say this with great respect to all future physicians - It's an issue of respect - both ways.

  32. If you are treating someone you know, it's really hard to be objective. If you are a physician and a patient, you deserve objective care just like any other patient. Therefore, there ARE other compelling reasons that physicians should not receive care from people they know well. If a patient was friends their doctor I'd imagine there'd be a similar conflict as well.

  33. Why is the choice between a competent trainee and an incompetent attending? Theres plenty of COMPETENT attendings out there. If im PAYING for a full doctor to handle my care, through cash/insurance premiums, etc, I see no reason why I should be seen by anything less than what I paid for! Why would I want to be used as a free training tool for a doctor, when Im paying good money to be seen? Now if it was a free service, hey, I would have no problem at all being seen by a resident or med student. But when Im paying through my nose for care (not everyone subsists on Medicaid/medicare), I, like any other customer, want value for my money.

  34. Hyperion: What I'm trying to say is that if trainees don't get trained properly because everyone refuses to be a "guinea pig", ALL there will be is incompetent attendings. Although it sounds like you feel that the guinea pigs should be the poor and old people who can't afford the kind of care you deserve.

  35. regarding physicians and their families not being treated by medical students, it goes both ways. When I was on obs/gyne as an SI3, one of the preceptors was expecting, and when she came back with a postpartum complication, I sure as hell didn't want to go assess her. (She was some sort of program director who was still teaching the week before this happened, and went into labour during the lecture.) Can you imagine the stress of treating your own boss? Definitely let the OB R1 handle that one..

  36. If students and residents are so reckless and dangerous and valueless to the patient care process, one would think that academic medical centers would be the worst-performing hospitals out there for patient outcomes, and that non-academic medical centers would have lines of patients waiting to get in for that better, student-free care.

    Wait, what's that? Academic medical centers provide BETTER care? Yes, students do add value to your care, and they cost very little. That 30 minute history that the useless student just took from you? Don't think the expensive attending would've given you nearly that much time. He'd still do his quickie exam and maybe wouldn't have caught that subtle finding. One of my med STUDENT colleagues recently caught a case of acute lymphoma in a young girl who had been seen the week before by a "real doctor" who missed the diagnosis because he didn't feel her spleen -- a measure the student took in the interest of being thorough and "practicing."

    Students have value. We have a fresh set of eyes, we are directly out of our basic sciences curriculum and our board exam studying, and we don't have the same biases that older docs have. Much of the information older docs have spent years learning turns out to be wrong due to the pace of medical advances, and having students around gives those old docs a drive to remain current and keeps them honest.

    This is not to say that there aren't very limited times when leaving a student out of the equation is appropriate. As a rule, though, students improve the quality of your care. The student you say "no" to is more likely to add value to your health care than to create a disaster, although both are possible. Exclude us at your own peril.

  37. @Fizzy: Your point about training is fine. It has to come from somewhere. But would you want to pay for a meal prepared by a head chef, but actually prepared by a trainee sous chef, because he has to learn somewhere? No.

    Do I feel that "the guinea pigs should be the poor and old people who can't afford the kind of care you deserve"? No.

    Do I feel that its sharp practice to charge me for being seen by a trained physician, while actually getting me checked out by an underpaid trainee? Yeah, of course! Now if you TOLD me that "Sir, youre going to be seen by a resident, and we'll charge you half the normal bill", hey, Id probably consider it a good deal, and so would many other patients, leaving plenty of people for doctors to practice on.

  38. I'm a survivor of child sexual abuse, and it takes me a long time to gather the courage to make the OB-GYN appt, and then go to it. I am generally worried I will embarrass myself by crying in front of them, or freaking out in some other way. It is a million times more difficult with a student poking around my vagina, when they too are obviously uncomfortable with it.
    - Butterfly
    P.S. I talk about the difficulty of survivors visiting doctors in my blog here: and of the difficulty of visiting gynos in my blog here:

  39. Hyperion: Your example makes sense for food, but not so much for health care, at least not to me. I don't believe that people who have more money are "owed" better health care, whereas I'm OK with them getting tastier food.

    Reasons: Actually, when I was a newbie intern, one of my young outpatients was a victim of sexual abuse. Even though I didn't really "know what I was doing", I spent two hours with her, and she shared a lot of things with me that were obviously very sensitive to her. She allowed me to do a pap on her, even though I wasn't entirely comfortable with it yet. At the end of the visit, her mother told me she wanted me to be HER doctor too because they were so happy with the care I provided. On the other hand, I've had tons of experienced ob/gyn attendings who made me feel really uncomfortable during my exam. So the moral is, experience doesn't equal sensitivity.

  40. @Fizzy: Like it or not, healthcare is a commodity. And what I pay for, I certainly am "owed", because intangibly valuable though the service provided by healthcare personnel is, its not free, and if I have paid for it, its not a favor, under any circumstance.

    Even though you may think my example works only for the food service industry, your reason for this line of thought is (forgive me) illogical. Your experience of providing wonderful healthcare to young victims of sexual abuse would have in no way changed if the hospital had charged a "residents rate" for it. YOU, as a trainee would have had the same experience, and your patient may have ended up better off for it (financially).

  41. Alas what Im taking away from this is that healthcare persons seem to think that they dont owe their customers any duty of care, and that the customer is owed nothing, but rather is not really a customer (even though he is charged like one), and that healthcare personnel are really benevolent dictators who can do whatever they want, simply because noone wants a bad outcome on their health. Well, thats fine in the short run, but in the long run, people will get wise.

  42. Hyperion: You're right... I absolutely do not think of patients as customers. I think of them as human beings who are entitled to health care regardless of their ability to pay. A restaurant will turn away a customer who can't pay, but the ER turns away nobody.

    Also, I'm confused... you say that you're paying for health care, but don't you have health insurance? Doesn't your health insurance then pay for your medical care?

  43. @Fizzy: Not at all. I do have health insurance. I pay for it. The insurance company does not operate a charity. They pay for my healthcare by operating on the basis of a balance of probabilities, which overwhelmingly (and rightly) exists in their favour. This is the system we have. Im glad you feel everyone is entitled to healthcare (I think so too). But why am I forced to take whatever care the system feel like giving me? Am I not entitled to demand better, when I too am a contributing member of this system?

  44. Just to add some "fact" to all the opinions being put out here, the research shows that teaching hospitals provide better care overall than non teaching hospitals.

    Perhaps with all the extra sets of eyes, hands and brains involved, there is less likely to be missed, more time spent with the patients etc etc.

    @Hyperion - you're never just seen by a resident or medical student. Your insurance won't pay for it unless the attending is involved as well. And as you mention it's a commodity, so you certainly have free choice to see a medical provider who does not have students or residents involved.

  45. ER Jedi: I think the reason teaching hospitals provide better care may be that the "experts" with the most knowledge usually end up in teaching facilities. Of course, there won't be new experts if they aren't allowed to pass on their knowledge because patients refuse to be seen by trainees.

    Hyperion: As the last commenter pointed out, you are allowed to choose your provider under most insurance plans. And if you hate being seen by students, you can choose to avoid teaching facilities. But if you do go to a teaching facility, I don't think the doctor should give you (or anyone else) any preferential treatment. I think it would be terrible if all doctors looked at a patient's insurance before deciding if they deserve to be given good healthcare or not.

  46. I have fairly severe joint hypermobility, and recently saw a rheumatologist who was training residents. I must say that I WANT students to see me (even if they have to Google things while I am there) so that somebody who has seen this condition is available when I need treatment. Otherwise the learning curve is pretty steep, as my body does some unusual stuff (injuries without loss of range of motion, etc.). I've learned that bringing a typed summary of my injuries and recovery strategies, along with an article from a medical genetics journal that defines the disease, helps the process along.

  47. "Patients in general have an ethical obligation to allow trainees to participate in their care."

    I had to read that twice to make sure I read that correctly. Absolutely not!!!! No one is ethically obligated to submit their body to someone in training just because they use the service. I pay for my care via my insurance premiums and as such, I have no moral or ethical obligation to help support a doctor's education by submitting my body for training purposes. Yikes!!! There are plenty of people who do not feel as I do and do submit their bodies for training purposes.

    By the same token, there are things that I do that I feel an ethical obligation towards that others do not (not medically related) and yet they also use the services.

    Using a service, whatever that service may be, does not obligate anyone ethically to support it.

  48. Thanks for this post! As an RN and pre-medical student working in an urban teaching hospital, I understand why people might not want to be seen by students/residents. We as nurses see the fallout of incompetent attendings and unsure students and interns when the patients call us in and say "Nurse, what do I have? Am I going to die?" (that's a fun one....yikes). I think the commenters have already hashed out all the reasons why it's frustrating and uncomfortable. But in the end, two things stand out in my mind: 1. The providers of the future need to be educated by DOING, not by watching. As many have pointed out, teaching hospitals provide better care. Not with commodities, not with better food or more convenient rounding, but BETTER care. As in better outcomes. As in, YOU LIVE AND YOU GET BETTER AND GET BACK TO THE LIFE YOU LOVE, instead of having an important part of your disease process missed but loving the gourmet food and purgo floors. 2. Patients should have the right to refuse, but I won't deny that it makes me uncomfortable. To me, it is morally unacceptable to allow healthcare to become an industry where only the poor and lacking of insurance are seen by the trainees. I suppose, in the end, they are getting a better deal of it (with better outcomes and all) but it's a disgusting and glaring signal of our country's ongoing prejudices. I've never been in the hospital as a patient, but I hope when I am, it's a teaching hospital.

  49. Well said, Katie. People seem to think that being seen by students and residents is some kind of sacrifice they make for the future of health care, when in reality being seen by a student, a resident, and an attending (as happens at teaching hospitals) is in fact likely to provide better care than the alternative, and at lower cost since the student is paying into the system. People who insist on seeing an attending only are getting worse care, and will suffer for it even if they don't realize it.

    And again, for the "health care is a business" folks, the hospital can choose to provide whatever service they want, including care that necessarily involves students. If you don't want that service, don't go to a teaching hospital, and get more expensive and less effective care somewhere else. That's how businesses work -- you, the customer, do not get to demand a particular service, including "only being seen by an attending", but you also do not need to "submit your body" to anything involuntarily, because you can simply not go to that place of business if you don't like what they are offering. Nobody forces you to receive health care in this country.

  50. I agree with the statement that it's ethically dodgy to choose to exempt oneself from necessary medical training. But certainly there are a lot of encounters with trainees that leave one worse off than if one demanded the fully trained professional. For example, my newborn daughter required daily heelsticks to track her jaundice and nail down the cause. Because I had recently finished nursing school the importance of learning opportunities was fresh in my mind. I let the trainee attempt to do the blood collection. After he failed twice, I requested that his trainer finish the procedure. I cried a bit on the way home and wondered if I had done a bad thing sacrificing my daughter's experience on the altar of principle. Two days later, we returned and were called back by the same trainee. He did a wonderful job that time. And at the same time both he and the trainer saw how well breastfeeding worked to calm an infant, even better than the sugar-filled "sweeties" they tried to foist on us.

  51. What an interesting discussion! As a newly minted intern, I certainly need to gain experience, and agree that in general, patients do have an ethical responsibility to allow training to occur. That being said, as an opera singer, when I had elective surgery that required intubation, I was VERY clear that the attending anesthetist was the ONLY person who was allowed to intubate me. There are certain situations (such as vocal cord damage for a singer) where my personal imperatives trump the benefit a trainee would have gained from intubating me.

    As with anything, a balance needs to be struck.

  52. Personally, my belief is that if you expect to see a fully trained doctor, you should not refuse to contribute to the training of future doctors. In certain sensitive situations (tons of examples in previous comments) where dealing with a student could negatively affect your health outcome, make sure that someone is supervising, but don't cut out the trainee on principle.

    As for the rich paying for only a fully trained doctor... that's not ethical. The population who expects to benefit from medical research / training should share the same risks of the research or training of that professional. Why should just the poor have to take the risk of dealing with someone less experienced?