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Some Patients Pay the Price for Physician Training
Anthony Rudine -- Hello again, friends. I have just recently finished my rotation in psychiatry and have now begun to delve into the world of obstetrics and gynecology. Allow me to be brutally honest -- I have been dreading this rotation for about 2 years. In recent months, my dread has steadily increased to reach a new high on the day before beginning the rotation.
My reasons for dread? Simply put, I realize that obstetrics and gynecology is a very personal specialty, which hinges on the trust of the physician-patient relationship. As such, I feel like an intruder.
I know that I am supposed to be there, that I have a legal right to be there, and that I have a duty to future patients to be there to learn. But I feel intrusive nonetheless. Unlike some other students, I do not consider myself one of those "cowboy physicians" who jumps into things without reflecting on the possible implications and consequences. So what are the implications?
Well, we are at a teaching hospital, obviously. This teaching hospital, like many, is attached to the county hospital, which means that we see many indigent patients, Medicaid patients, and immigrant patients. From what I can surmise, no female would "choose" to go to a clinic where they will have their most private examinations performed by a student; yet, they have little choice.
Medical education is a strange beast to tame. As a society, we have come to accept the idea that, for the betterment of future generations, physicians must be trained in an environment such as this; naturally, some pay the price -- by being examined by students.
I am not saying that this is a bad way of doing things, I am just saying that there is a disparity here. In the book "Complications," the author states that when his son had heart difficulties, and it finally came time for the surgery to be performed, he requested that the resident physician not perform the surgery -- even though he was a resident physician himself -- because he simply wanted the best possible care for his child.
The interesting fact here is that this surgeon knew how things worked, and chose to bypass the system. While it is fair to say that most parents would choose the best care for their children, few are given the choice between a student, resident, or attending.
The dichotomy of care thus continues.
November 3, 2006 | Permalink
Comments
Dr. Rudine, your concerns do you credit, but you may not realize how many of us have come to be endlessly grateful for the care we have received from students, interns, and residents. My ovarian cancer debulking surgery was performed by a full professor and a second year resident, and I'm glad to have had the senior doctor in the OR. But it was the resident who made sure she was at my beside at 5:00 am before I awoke so that I didn't find out about the unplanned colectomy/colostomy from someone else. It was an intern who noticed the stye in both eyes, not the oncology attending, and who gave me a script for Bleph-10 to save me a trip to the GP and more expense. Yesterday, it was the first-year resident who called me back about a post-chemo problem and who actually took the time to listen to what I was saying. So what if he had to go ask the oncologist and then get back to me? He relieved my anxiety and saved me from an unnecessary trip into the office, which would probably have ended up with an unnecessary antibiotic treatment. That might not have been his goal; it may not have occurred to him that some of us get overtreated because our Senior Doctors stop listening to us after the first three words and just go into auto-treatment mode. My resident, bless him, has not yet been taught to stop listening, to stop asking questions. Sure, it's tedious at times to be treated at a teaching hospital; my record so far is giving history six times in four hours in one ER visit. But if I am teaching you something, then maybe there's some small redemption of the evil fact of my having cancer. In any case, my definition of "the best care" most certainly includes students and young doctors. Hold on to your respect for the intimacy of care, but use it to help you make a difference in our lives, not avoid contact with us out of misdirected respect. Godspeed you.
Posted by: Chemo Lady | Nov 7, 2006 1:20:37 PM
Anthony, I hear you 100%, and I agree and applaud your concerns. I had an experience in a community medicine rotation where I felt like I was part of a violation due to the disrespectful treatment by a physician to a poor woman during a pelvic exam, even though in that case, I did nothing but observe. I mention this only to say I'm sensitive to the subject you bring up, and I think it shows good moral character on your part.
However, some of the best treatments occur in teaching hospitals, and while there will always be the poor, the disenfranchised, etc. that have little choice, many people with a choice still go to the "Big U" health centers knowing students/residents are there because there is still the care that comes from the "Big U" attendings. Maybe you'll come across a woman with cervical cancer or a high-risk pregnancy who elects to be there and see a different perspective on being given the privilege to attend to them.
Posted by: Enrico | Nov 7, 2006 3:48:18 PM
I am a pre-med student having also read Complications. I totaly agree sometimes it is the price that we pay for education. Never the less we should never lose a patients dignity or lose our own empathy for them as long as we are physicians. Too often we can become caught up in our own work and forget the great gift these patients have given us by allowing us learn through them whether they had a choice or not.
Posted by: Katie | Nov 7, 2006 5:33:59 PM
To play the devil's advocate I would have to say that while it does inconvenience the patient's to have multiple exams at times or to have less technically skilled persons perform procedures it is to the patient's ultimate advantage. By having such a huge team to care for patient's it ensures that someone will catch a problem/ask the right question/get the right answer. I was on a REHAB medicine rotation in the beggining of my third year and I diagnosed basal cell carcinoma on a patient suspected of having ring worm by the resident team. So I think yes, it's more invasive, more inconvenient, but it's necessary to care for the patient's that we have.
Posted by: Dr Phil | Nov 8, 2006 12:41:45 AM
It seems like you need to differentiate between a pelvic exam and heart surgery. As a 4th year medical student I can certainly do a pelvic, but cardiac surgery is out of the question. For most patients having several levels of students and residents will likely result in better care. But you also need to be very careful about how your attitude influences your patients. On OB, if you are caring, supportive, and relaxed, your patients will appreciate your being there, even if you are just a student. However, if you act like you shouldn't be there, that will be very evident to your patients and you probably shouldn't be there. I wonder that if you "dread" certain rotations how dedicated you really are to caring for patients. The focus should never be on you. There is a huge middle ground between being a "cowboy" and an "intruder". Perhaps your medical school needs to do a better job of preparing students to interact with patients.
Posted by: Edward | Nov 8, 2006 12:53:48 AM
Saddle up cowboy... It is time to put aside the social stigma of looking at another person's "privates" and delve into the realization that a physician's responsibility is to poke and prod all the appropriate orifices. Medicine does not lend itself well to one who is prudish. I cannot count the number of times very important findings were missed in the social history of an H&P because the clinician was too embarrassed to ask specific questions. It's not an option, it's our job. Back to the rodeo...
Posted by: Michael | Nov 8, 2006 11:37:42 AM
I'm 34 and on Medicaid. I have numerous medical issues and Medicaid has saved me untold thousands of dollars! Should my divorce and medical problems suddenly classify me as "indigent patient, Medicaid patient, and immigrant patient"? Don't judge a patient based on income status. Some of us are very intelligent, despite this- or our medical issues. A good doctor is one that sees me as an individual first- not a social status or collection of symptoms/diagnoses.
Posted by: Jennifer | Nov 8, 2006 2:01:31 PM
Dear friends,
I´m from Brazil and i´m on the last year of the medical course. Here in our country, where 70% of our population are very poor, and there is not enough physicians, we have an important function in the teaching hospitals as in the primare care units in the countrysides. The patients, most of the time, feel very pleased with our presence there, and we feel the same for the opportunity they give us to learn and help them at the same time. So, i think that kind of concerns, although very positive, depend on your point of view and on your country social conditions.
Posted by: Dadson Leandro | Nov 8, 2006 4:47:18 PM
I think that poor patients that go to university hospitals are aware of the risks involved with a student doctor. I think you need to put aside your doubt. Yo are most likely to mess up if you think too much about it than by going balls to the wall. You need to trust that you are a good doctor. And that if you screw up, it's all part of being human and a doctor.
Posted by: EJota | Nov 8, 2006 5:18:58 PM
It is great that you are sensitive to the patients' feelings. I would suspect that is one of the biggest complaints patients have- doctors who don't care. But you can also take a little bit of comfort from knowing that women have to have pelvic exams every year of their lives from ~18-50, so although we do dread them to some degree, they are also just a routine part of women's health. Like someone mentioned above, if you are calm and confident, and just do what you need to do, your patients will most likely not mind their contribution to your learning efforts.
Posted by: | Nov 9, 2006 2:31:32 AM
"...no female would "choose" to go to a clinic where they will have their most private examinations performed by a student..."
Pish-posh. It's more fun that way. I get to feel like a teacher instead of an object. I can ask lots of questions and not feel like I'm imposing so much. If the students are standing around watching as an experienced doctor explains what he's doing, I get to feel like a med student a little bit too. Also, when the doctor is deep into his work and a student's attention wavers a bit from "down there", and they notice me grit my teeth and pull myself up a bit on the table, they can often step in fast with a pillow under my knees, or a piece of tape to secure my back-of-the-hand IV, or a timely question to distract the doctor for a second so I can take the breath I've been holding.
I was in for a percutaneous nephrostomy a week ago, naked butt up on the CT scan table (allergic to IVP dye, thanks) in front of my excellent radiologist and two strapping young heroes of medical students. I appreciated feeling like I was helping with an interesting lesson instead of burdening a busy doctor with yet another daily chore. Plus I was too visually distracted to feel embarrassed. :)
Posted by: speedwell | Nov 9, 2006 12:23:36 PM
Wow, great post! You bring up some great points.
Another thought is that you should never get sick on July 1.
I have been a silent lurker of your blog and just wanted to let you know that I enjoy it.
Posted by: Sarah Bellham | Nov 12, 2006 5:54:56 PM
hello, I don´t speak english a lot, but I understood this article. I only want to say, that in my country, Peru, these cases are more frequently, and we should prepair to act with the patients, of the better way.
Posted by: oscar | Nov 16, 2006 7:10:03 PM
hi, i'm a fourth year medical student and i'm from Malaysia.Here things are done differently. patients are usually informed about the hospital status; ie:if its a teaching hospital or not.they are given the option.however, i must admit, there are times when i feel obtrusive, thus i always ask for permission(as we all do).i guess it makes me feel less guilty.the funny thing is, in malaysia its like threading on thin ice, as we have to respect the different cultures, and try to communicate to our patients at the same time(in the thier respective language-bahasa malaysia,english,tamil,mandrin etc)for not many speak our national language or english.
Posted by: Lalitha | Nov 25, 2006 10:06:02 AM
In my first clinical year, I also feel that I, a merely medical student, couldn't give the best for the patients. Thankfully, my university in Indonesia has programmed the hardest subjects (Obgyn, Surgery) in the last year so we will be more prepared by then.
When I examine my patients, I give my best for them. I studied first and don't want to examine patients when I don't know exactly what I do.
Of course I'm not as good as experienced doctors but the thought that I'm doing my best for them to become a good doctor in the future lighten me a bit.
And I try to see my patients as my familiy, my sister, my parents, my grandparents, so I try not to be too curious or too annoying for them.
Posted by: doodles | Dec 1, 2006 3:03:30 AM
Dr Anthony,
Though "intruding" a procedure and probably meeting some pretty obnoxious and difficult patients, a pelvic exam is probably the only clinical way to hazard a clnical diagnosis in most gynaecolobical and definitely obstetric cases. being so important, some respectable, confident and professional approach needs to be employed. For medical Students to develop this confidence, they need the exposure but must first be taught the best approaches and Ethics.
In my Medical school, University college Hospital Ibadan, Nigeria this is done first, early in the OB/GYN rotation and thus we keep certain things in mind when "intruding". Your skills are important, and your patient needs professional and thorough attention. both now and in the future. So bring yourself to appreciate what skills you need to learn and find a pleasant and professional way to go about it.
Posted by: Ekpenyong | Dec 22, 2006 7:21:51 PM
