The Ethics of Shadowing: When the Line is Crossed

The Ethics of Shadowing: When the Line is Crossed

High school juniors, seniors, and pre-medical college students frequently shadow practicing physicians in order to gain insight into a medical career. Additionally, pre-medical students shadow physicians in order to gain clinical experience and required shadowing hours for medical school. No one shadowing experience is alike, but students shadowing physicians often see a wide range of cases depending on the specialty of the physician that they are shadowing. Shadowing provides a valuable experience for students because it gives a brief glimpse to what daily life is like as a physician and can increase the likelihood of students going into medicine. However, it is important to ask-  Are shadowing experiences ethical on the patient’s behalf?  The answer to this question is a very tricky one to answer. In some contexts, shadowing can be done ethically on a patient’s behalf through strict established guidelines and explicit patient consent. When the practice of shadowing is done ethically, by adhering and following guidelines so that a patient’s privacy is protected, shadowing can be a positive experience for both a student and patient because a student is offered a glimpse into what life as a physician is like and is actively learning through hands on experience, and the patient’s privacy is protected. However, when the practice of shadowing is not conducted correctly it can be physiologically and physically unethical for patients because shadowing can be an invasion of a patient’s privacy and the confidentiality of the patient can be put at risk.

In February 2017, I had the opportunity as a high school senior to participate in my local hospital’s shadowing program. This invaluable and eye-opening experience confirmed my notion to pursue a career in medicine and showed me what the daily life of a clinical physician was like. The shadowing process was very strict. There were many HIPAA guidelines I had to follow, copious amounts of paperwork to fill out, and a required dress code. Each time I entered the room with the clinical physician, she explicitly asked the patient or the patient’s parents if it was okay if I observed the patient-doctor interaction and the procedures that she (the physician) was conducting. Because I shadowed a pediatric emergency physician, the process was even more rigid and controlled because young children, one of the most vulnerable patient populations, can’t advocate for themselves. By asking for explicit consent from the patient and the patient’s parents and explaining what exactly I was doing, the physician I shadowed followed regulations However, not all physicians do, even when strict guidelines are in place. When physicians don’t follow regulations as they should by not explicitly stating a student’s purpose, it creates a situation that is very ethically wrong because a patient’s privacy and confidentiality are violated and a patient can psychologically be affected in sensitive situations. As surprising as it is, it occurs quite often in the settings of teaching hospitals and traditional doctor’s offices. In this situation, a patient’s confidentiality and privacy are put at risk, because they are not made aware that the student observing is either just a high school or college student and they think the student is already in medical training.  Another context in which a patient can psychologically be put at risk is when a shadower observes a sensitive situation such as a pelvic exam or a rape victim. These patients aren’t always in their best state of mind where they are thinking clearly and coherently because some may patients may be paranoid or anxious when making medical decisions for themselves and can therefore ethically be put at risk because they may feel pressured to give consent or be too traumatized to make a clear decision. Additionally, patients may not be as willing to share valuable sensitive medical information in front of a high school or college student, but they may be pressured by the presence of the doctor into letting the high school or college student stay in the room because they think it will benefit the student.  

Shadowing can be a very emotional experience for both a patient and the observer, because not only does shadowing a physician offer a glimpse into the life of a doctor, but it shows a patient in their most vulnerable state.  Patients, in most cases, will consent and allow shadowers to stay when a patient feels comfortable discussing the topic of their medical case with their doctor in front of the student. I believe most patients allow it for the student’s benefit to learn because they understand students are observing physicians in order to gain insight and real-life experience. Nonetheless, when a patient feels uncomfortable with a shadower observing and patients don’t provide consent, then the shadower should leave the room immediately. It is already hard enough sometimes for patients to trust their doctors, so in the context of sensitive cases like rape victims or pelvic exam, it would be highly unprofessional for trained physicians to ask a patient to let a novice observer stay and observe an already raw and emotional situation for a patient. During my shadowing experience in high school, I observed a rape victim. In this particular situation, I followed the physician I was shadowing into the hospital room and waited outside the curtain. The physician didn’t even bother to ask the patient if I could enter the vicinity, because she knew that the patient was a rape victim and that it would be morally wrong to ask consent for me to stay because rape victims are in a fragile physiological state of mind. However, the patient saw me before the physician finished closing the curtain and asked who I was. The clinical physician stated my purpose there and the patient insisted that I stay and observe. Maybe they allowed me to stay based on the belief that they wanted me to understand the repercussions of what was like to be a rape victim and to be in the vulnerable position of having no control over a situation. Regardless of her reasons, I truly believe this patient was not in the best frame of mind to provide consent for me to observe, but did so anyway.  Her emotional and physical state was heart-wrenching and the whole experience left me somewhat shell-shocked. It also left me questioning whether it was really ethical for me as a high school senior to see a patient in such a vulnerable state. Perhaps, the answer here is virtue ethics for both me as a student and clinicians in general. Even though the patient insisted that I stay, should I have allowed myself to do so or should I have respectfully declined the offer?  Did I take advantage of the situation and the patient as an opportunity to learn?  Additionally, should the clinician have intervened on the patient’s behalf and advised me to stay out, even though the patient insisted that I entered the room?  All of these are tough questions to answer. Based on my own virtue ethics, I think it was valuable for me to stay because I observed the experience of what it was like to be a rape victim and truly empathized with the patient.  However, speaking on the patient’s behalf, I feel I should have left because the patient wasn’t in the right frame of mind. In some ways, I regret putting the patient in that position.  Additionally, I feel the clinician let me stay because she felt it was a valuable learning experience for me, but I don’t know if she was truly thinking about the patient at the moment she decided to let me stay.  It is already hard enough for patients to trust their own doctors, which is why it’s wrong from a virtue ethical standpoint for students to observe sensitive cases. In theory practicing clinical physicians won’t allow students in the room, except in a rare situation.

In a study published on the National Institute of Health website conducted by Robert G Bing-You, Victoria M. Hayes, and Jennifer L Skolfield, thirty-two patients agreed to have college students shadow their physician and participate in interviews afterward about their patient experience. The findings of the study were that many patients had neutral feelings about having a college student observe their visit and 21.9% of the patients interviewed felt the college student had a positive effect on their visit.  Additionally, no patient felt that having a college student present affected their ability to maintain a trusting relationship with their physician.  Furthermore, the majority of patients had no concerns about confidentiality, whereas 12.5% of patients had concerns (three patients), or didn’t answer the question (one patient). Also, in most of the interviews conducted, patients found their visit was a positive experience because they believe it positively affected the college student’s learning experience in gaining real life experience outside of the classroom.  The researchers concluded that most patients felt as if shadowing was a beneficial experience to students and that it only raised ethical concerns when sensitive issues were involved. [1]

Comparing this study to my personal experience, it is evident that shadowing can result in positive benefits. However, the study did raise concerns when sensitive issues were involved.  Keeping this in mind, doctors need to be more vigilant with proper introductions of observers and become more sensitive to a patient’s mindset and ability to make decisions for him or herself. In the practice of shadowing, the patient should be made top priority and if at any time a patient feels uncomfortable with a student shadowing, the observer should exit the room at the patient’s wishes, because only then is shadowing truly ethical.

References:

[1] Bing-You, Robert G., Victoria M. Hayes, and Jennifer L. Skolfield. "Physician shadowing by college students: what do patients think?" BMC Research Notes. 2014. Accessed October 13, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975134/.

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