MS3 Professional Boundaries and Patient Education

[Ammo Baba]

Hey all,

So I just started my Core rotations with OBGYN, so far the my Preceptor has been super nice and patient with any quirks that have come along with this being my first rotation. However a PA who works with the Doctor told the Clinic manager that I overstepped my boundaries on some patient education regarding the risks of inheriting Sickle Cell disease and the benefits of screening partners with unknown Sickle cell trait carrier status. Long story short the manager understood where I was coming from and asked that I just discuss such matters in front of the Doctor (who was away at the time performing a hysterectomy).

My real question is how much information can I really dispel about topics I am familiar and well educated on if patients ask me? I was an EMT for a couple months after college and a tutor during basic sciences, so its kinda become a gut reaction for me to explain things (at my current level of training anyways) to people who ask. I never make diagnosis in or outside rotations or overstep my boundaries as a student and always refer the patient to ask my attending for further discussion and questions.

BTW I also apologized to the PA for crossing any professional boundaries and any perceived over-zealousness.

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[libertyyne]

Hey all,

So I just started my Core rotations with OBGYN, so far the my Preceptor has been super nice and patient with any quirks that have come along with this being my first rotation. However a PA who works with the Doctor told the Clinic manager that I overstepped my boundaries on some patient education regarding the risks of inheriting Sickle Cell disease and the benefits of screening partners with unknown Sickle cell trait carrier status. Long story short the manager understood where I was coming from and asked that I just discuss such matters in front of the Doctor (who was away at the time performing a hysterectomy).

My real question is how much information can I really dispel about topics I am familiar and well educated on if patients ask me? I was an EMT for a couple months after college and a tutor during basic sciences, so its kinda become a gut reaction for me to explain things (at my current level of training anyways) to people who ask. I never make diagnosis in or outside rotations or overstep my boundaries as a student and always refer the patient to ask my attending for further discussion and questions.

BTW I also apologized to the PA for crossing any professional boundaries and any perceived over-zealousness.

educating patients of their decisions is part of the gig, I dont think you overstepped any boundaries there. Im unsure if you were handing out medical advice or suggestions which would have clearly crossed a line.

I would talk with your attending and see where they draw the line. Different attendings have different levels of comfort with different students, some will give you graded autonomy. Some of my attendings are completely ok with me discussing results with out them being present. Some doctors love that I educate patients when I am with them. Some even send me rooms to try to talk about the benefits of screening /procedures that the patient refused previously . Some want me just collect information.

I always shy away from talking about results or medical decision making because I dont want to say something that the attending patently can disagree with later on.

 

[Ammo Baba]

educating patients of their decisions is part of the gig, I dont think you overstepped any boundaries there. Im unsure if you were handing out medical advice or suggestions which would have clearly crossed a line.

I would talk with your attending and see where they draw the line. Different attendings have different levels of comfort with different students, some will give you graded autonomy. Some of my attendings are completely ok with me discussing results with out them being present. Some doctors love that I educate patients when I am with them. Some even send me rooms to try to talk about the benefits of screening /procedures that the patient refused previously . Some want me just collect information.

I always shy away from talking about results or medical decision making because I dont want to say something that the attending patently can disagree with later on.

The patient asked me the difference between sickle cell trait (which she had) and Sickle cell disease and the chances her unborn child could inherit the disease. I just drew her a punnet square and explained that the baby had a 25% of getting Sickle cell disease if her partner also carried the trait. I then told her my attending could speak to her more about screening her partner for Sickle cell trait if he was unsure about his status.

My attending usually lets me educate patients on patho-physiology type concepts if the patient has disease specific questions but I always refer the patient to ask him regarding procedures, test results, medications, or anything I'm not 100% on.

I guess I should make it a rule of thumb to ask my preceptors and attendings how involved they would like for me to become at the beginning of the rotation.

 

[libertyyne]

The patient asked me the difference between sickle cell trait (which she had) and Sickle cell disease and the chances her unborn child could inherit the disease. I just drew her a punnet square and explained that the baby had a 25% of getting Sickle cell disease if her partner also carried the trait. I then told her my attending could speak to her more about screening her partner for Sickle cell trait if he was unsure about his status.

My attending usually lets me educate patients on patho-physiology type concepts if the patient has disease specific questions but I always refer the patient to ask him regarding procedures, test results, medications, or anything I'm not 100% on.

I guess I should make it a rule of thumb to ask my preceptors and attendings how involved they would like for me to become at the beginning of the rotation.

that sucks. I dont see anything wrong with that, it is a little bit of prognosticating though. But honestly I would just shrug it off as the manager not knowing anything about anything. But having explicit permission from your attending hopefully protects you going forward.

 

[thumbz]

For what it's worth, perhaps the PA was more nervous about getting into the realm of genetic counseling. It's a hot topic issue, and at my academic shop I can't order any genetic testing myself but rather have to refer patients to genetic counseling first. So it may not be the level of counseling, but rather the counseling you gave. For example, it's awkward for me to come in after my MS3 tells the patient I can test for something that I can not.

On the more cynical side, the PA may have been upset that you were doing more than they often have the opportunity to with the patients (for one reason or another). It seems a little passive aggressive for them to complain about you to the clinic manager rather than discuss it with you directly, or just give your attending the heads up so they could address it if they thought it was an issue. If I came to find out someone complained about a student to the clinic manager and didn't give me a chance to address it first I would be upset with the PA.

 

[libertyyne]

For what it's worth, perhaps the PA was more nervous about getting into the realm of genetic counseling. It's a hot topic issue, and at my academic shop I can't order any genetic testing myself but rather have to refer patients to genetic counseling first. So it may not be the level of counseling, but rather the counseling you gave. For example, it's awkward for me to come in after my MS3 tells the patient I can test for something that I can not.

On the more cynical side, the PA may have been upset that you were doing more than they often have the opportunity to with the patients (for one reason or another). It seems a little passive aggressive for them to complain about you to the clinic manager rather than discuss it with you directly, or just give your attending the heads up so they could address it if they thought it was an issue. If I came to find out someone complained about a student to the clinic manager and didn't give me a chance to address it first I would be upset with the PA.

in his defense he was just suggesting an electrophoresis for the partner. But i agree with your assesssment.

 

[thumbz]

in his defense he was just suggesting an electrophoresis for the partner. But i agree with your assesssment.

Which I agree seems like such a simple thing. But then what happens when the partner learns he's sickle cell positive, this causes the couple to decide not to attempt conception due to the risk which in turn leads to divorce, depression and subsequently suicide. I agree, the example sounds absolutely ridiculous but it happens and it's why genetic counseling exists. Do I agree with it? Honestly I'm not sure, but there's a reason I don't do caths and genetic testing is quickly becoming its own subspecialty as well. So I defer to the requirements of my institution. That and because I love my job and am conflict adverse =P

 

[Ammo Baba]

Which I agree seems like such a simple thing. But then what happens when the partner learns he's sickle cell positive, this causes the couple to decide not to attempt conception due to the risk which in turn leads to divorce, depression and subsequently suicide. I agree, the example sounds absolutely ridiculous but it happens and it's why genetic counseling exists. Do I agree with it? Honestly I'm not sure, but there's a reason I don't do caths and genetic testing is quickly becoming its own subspecialty as well. So I defer to the requirements of my institution. That and because I love my job and am conflict adverse =P

The Clinic/ Hospital I do rotations at does indeed do Gel electrophoresis, I actually had another patient a couple of days prior who likewise had Sickle cell trait (and was also pregnant) but did not know the carrier status of her partner. My attending told her it was something the clinic offered and they could come in and have it done and discuss the results at a later time. I haven't had any experience with more complex disease like Cystic fibrosis, Tay Sach's, Huntington's ect, but partner's seeking genetic counseling before conceiving are referred to a genetic counselor. Im unaware if the clinic does anything more risky/ invasive like amniocentesis or chorionic villus sampling.

 

[operaman]

I agree OP - based solely on your description of events I don’t think you inherently overstepped anything here. It’s also an area of medicine with a lot of controversy and patients tend to misunderstand things even when it’s pretty straightforward. For all you know the patient told the PA an entirely different story (and probably did).

This only gets harder by the way. Even as you progress through training and are making diagnoses and really counseling patients, you still have to hedge a bit so you don’t leave any landmines for your attendings. Now even though I know exactly what my plan For something will be in 6 months when I graduate, I still leave things a bit open and vague.

Personally I have no problem when students talking to patients and discussing things within their own level of comfort, but I also expect them to fully convey their status as a student and remind the patient that their final plan will be decided with the attending.

 

[NickNaylor]

I can understand both perspectives. What you did was completely reasonable and perfectly appropriate for a medical student to do, in my opinion, however I can also understand the anxiety from the perspective of non-clinicians as you are veering dangerously close to practicing medicine without a license. I would agree with the clinic manager that this kind of stuff should be done with the attending present just to make sure that you don't incorrectly counsel the patient, even though it's basic stuff. "Medical student" does not, legally, give you any meaningful privileges when it comes to talking with patients.

 

[AnatomyGrey12]

It seems a little passive aggressive for them to complain about you to the clinic manager rather than discuss it with you directly, or just give your attending the heads up so they could address it if they thought it was an issue.

The fact that the PA went to the clinic manager, instead of the attending or even the student themselves, is really weird to me. The clinic managers at all the places I've been literally never interact with the students in any capacity outside of maybe helping coordinate our schedules.

I can understand both perspectives. What you did was completely reasonable and perfectly appropriate for a medical student to do, in my opinion, however I can also understand the anxiety from the perspective of non-clinicians as you are veering dangerously close to practicing medicine without a license. I would agree with the clinic manager that this kind of stuff should be done with the attending present just to make sure that you don't incorrectly counsel the patient, even though it's basic stuff. "Medical student" does not, legally, give you any meaningful privileges when it comes to talking with patients.

I think the non-clinicians honestly shouldn't have a role in this at all. I don't think it's unreasonable to explain basic medical stuff to patients without an attending, in fact, most attendings have told me explicitly that they expect me to. This is obviously with the caveat mentioned above that I make it clear I'm a medical student and any final recommendations, plans, tests, explanation will come from the attending or senior resident. If there is a problem with a student potentially over-stepping it should go to the attending who should be the one to decide if the student actually did overstep. Clinic managers have no clue as to the clinical side of medical training, so shouldn't be the ones approaching students telling them what to do, or not to do, with patients.

 

[Goro]

The fact that the PA went to the clinic manager, instead of the attending or even the student themselves, is really weird to me. The clinic managers at all the places I've been literally never interact with the students in any capacity outside of maybe helping coordinate our schedules.

As an aside, you'd be surprised at how few people understand the concept of chain of command in any profession, not merely the in the clinic.

 

[GoSpursGo]

It's tough--like others, I can see different attendings being either uneasy or totally fine with you explaining that kind of information. It depends on the attending's comfort level in potentially cleaning up situations where you misspeak and the institution's policy regarding genetic counseling. I think it's probably fair game to counsel patients who ask you questions as they did in this situation, and expect that if you cross a line or come close to that you can get feedback from your attending.

I agree that the PA went to the wrong person to "lodge a complaint," though. They should either have been able to tell you that him/herself or discuss with the attending, who is responsible for giving you feedback.

Personally, I wouldn't mind a med student saying any of the things you said, perhaps with the caveat that it would be nice to tell her the prevalence of sickle cell trait in the general population if it didn't seem clear to her that the risk is not ACTUALLY 25% for her child.

 

[Neopolymath]

The PA's behavior is typical of today's society unfortunately. If you neighbor is loud, do you address this with them as an adult with concerns or do you call the SWAT team on them? The modern man is apparently unable to do the reasonable thing anymore.

Address this with your attending and then ignore this dopey loser.

 

[NickNaylor]

The fact that the PA went to the clinic manager, instead of the attending or even the student themselves, is really weird to me. The clinic managers at all the places I've been literally never interact with the students in any capacity outside of maybe helping coordinate our schedules.



I think the non-clinicians honestly shouldn't have a role in this at all. I don't think it's unreasonable to explain basic medical stuff to patients without an attending, in fact, most attendings have told me explicitly that they expect me to. This is obviously with the caveat mentioned above that I make it clear I'm a medical student and any final recommendations, plans, tests, explanation will come from the attending or senior resident. If there is a problem with a student potentially over-stepping it should go to the attending who should be the one to decide if the student actually did overstep. Clinic managers have no clue as to the clinical side of medical training, so shouldn't be the ones approaching students telling them what to do, or not to do, with patients.

Whether non-clinicians should or should not have a role in this kind of stuff is somewhat irrelevant - it is a fact of practicing medicine at present, so I would get used to it.

 

[GoSpursGo]

Whether non-clinicians should or should not have a role in this kind of stuff is somewhat irrelevant - it is a fact of practicing medicine at present, so I would get used to it.

True to an extent, but non-clinicians often are very service-oriented and don't really "get" how things work in a teaching environment. I don't think it's unreasonable to educate the non-clinicians that ultimately the attending physician is the only who can decide what the appropriate boundaries for a medical student is on the team.

That level of counseling may be outside of the wheelhouse for the non-clinician, but it shouldn't be for a physician, and part of being a medical student is practicing those kinds of patient interactions at the level that is deemed appropriate to his or her training.