Shadowing smackdown

[LizzyM]

---

Members do not see this ad.

Check out the Letters to the Editor in this most recent issue of JAMA in response to Elizabeth Kitsis' essay against shadowing.

June 15, 2011; Vol. 305, No. 23


URL: http://jama.ama-assn.org/content/vol305/issue23/index.dtl?etoc

You may need a subscription to view the letters.... a good reason to make the acquaintance of a hospital or med school librarian... or a friendly doc with a subscription.

 

[raltima07]

BRB making connections

 

[NKChemEng]

The arguments against shadowing aren't without their base. If I were a patient, I'd be concerned for my privacy as well. But, I understand that students are trained in HIPAA nowadays, and being a volunteer myself, I deeply respect patients' privacy needs.

I like the point that the physician needs to address the observer's presence and clearly give an option to accept or decline.

 

[HH Holmes]

I like the point that the physician needs to address the observer's presence and clearly give an option to accept or decline.

I can't read the article (no sub), but I totally agree with this. The surgeon I'm shadowing now does this with every single patient he sees... Even patients who are regulars and know me by name (there's a few), he still asks if I can come in. I find it perfectly reasonable, and I'd feel weird walking into a room unless I was welcome to observe and ask questions.

 

[NKChemEng]

For those that don't have subs, this is an excerpt that I quote that I found particularly important. It beautifully states the reason why shadowing is, in fact, very important for our growth.

"When we were premedical students, clinical involvement
elucidated our understanding of the patient-physician relationship.
While biology and organic chemistry taught us the
scientific basis for medicine, such course work neglected medicine’s
practical side. Shadowing, however, exposed us to the
role of insurance companies and paperwork, patients’ and families’
narratives,2 and the need for confidentiality. This knowledge
was invaluable for understanding medical practice."

 

[LizzyM]

I like this line from Dr. Teitz at U Washington admissions office regarding the debt taken on by US medical students as an argument for shadowing as a pre-med:

"No one would buy a Ferrari without test-driving it. "

 

[NKChemEng]

"No one would buy a Ferrari without test-driving it. "

Same! I love that one.

 

[MRSAful Fate]

For those that don't have subs, this is an excerpt that I quote that I found particularly important. It beautifully states the reason why shadowing is, in fact, very important for our growth.

"When we were premedical students, clinical involvement
elucidated our understanding of the patient-physician relationship.
While biology and organic chemistry taught us the
scientific basis for medicine, such course work neglected medicine’s
practical side. Shadowing, however, exposed us to the
role of insurance companies and paperwork, patients’ and families’
narratives,2 and the need for confidentiality. This knowledge
was invaluable for understanding medical practice."

I can't fathom commiting to medical school without shadowing or being exposed to medicine and what doctors do through work experience. How would you have any clue what you're getting into? What if your first clinical exposure was as an MS3 and you hated it? It would be way too late to change course unless you're filthy rich and can absorb the debt.

 

[NKChemEng]

The main point, unfortunately, that Kitsis makes, is not that shadowing is unimportant. She's concerned with patient's privacy. In her original article, she states (I paraphrase) that shadowing by medical students makes for more ethical and humane physicians. And, she says that these are already committed students that will in fact go into the field, and have been chosen as such. To Kitsis, college students that shadow are not like that. She states that they are still choosing their career path. A medical student will shadow for actual experience, while a college student shadows simply to choose.

I don't know if I agree with her on this. Yes, college students have the freedom to steer away from medicine upon seeing what a physician does. But I feel like the college students who make the effort to shadow already have an interest in medicine, and are getting much more out of shadowing than simply a benchmark upon which to make a career choice. I WOULD be worried if it were a high school student shadowing, but even then, there are a bunch of responsible high school students. I guess the problem is with the level of commitment. Patients and physicians should understand that college students are not "unworthy." I've always been treated with fairness and respect, even as a college student, because I was mature in my interactions with physicians and patients. It all depends from student to student. I still think that most premeds that shadow are ready for it.

 

[eugenierose]

I have to say that the whole having kids who have no idea what the hell is going on and who, on majority, probably should not be trusted with a rock's confidences, much less a real patient's, is a bad idea. I don't believe for a second that necessary precautions with regard to confidentiality, maturity, respect, or the purpose of shadowing excursions are routinely executed.

At my own house, until this past summer, there was absolutely no restrictions or rules on surgical observers. If you could get scrubs, you were in. To abuse the blind trust of patients-- many of whom can barely expose their vulnerabilities to their primary providers and don't even consider ancillary personnel until long after their consents are signed-- to the hubris of high-schoolers and undergrads is obscene.

" physicians have other duties to their patients that are breached by college student shadowing, including maintaining privacy, maintaining confidentiality, avoiding coercion, and avoiding misrepresentation." <--- this is key. and we all know that no one gives a **** about HIPAA, forms or not.

If someone really wants to see what medicine is about, filing and giving directions are going to tell you much more than some 50-something lady who doesn't know she can kick you out and keeps lying to her PCP because she doesn't know who you are or who you're going to tattle on her to.

 

[TheMightySmiter]

Don't have access to the letter from home, but I agree completely with the quoted statement. The physicians I've shadowed have always asked each patient whether or not they are okay with my presence, and there have only been a couple of occasions when the patient has said no.

 

[ucbsmd]

Even after working in clinical research for a year now, I feel I got a much better understanding of what being a physician entails through the shadowing. You get to see the fun parts such as surgeries, but you also see the more mundane things such as the endless amounts of charting. Elizabeth Kitsis suggests that "Students can learn about the more mundane aspects of medicine by spending time with medical administrators." While I agree you can see what an administrator does in healthcare, you will miss out on see what a physician does, which is the reason that people choose to shadow to begin with.

 

[NKChemEng]

Would it be realistic for some sort of filtering process/application process to exist for shadows? I realize that most doctors are pretty open to having students observe. But they don't just take anyone off the street - in your guys' opinion, do you think that students are mostly respectful and trustworthy, or clueless?

 

[Narmerguy]

Where is the original letter? I can only see the responses.

 

[NKChemEng]

http://jama.ama-assn.org/content/305/10/1029.full for the original.

 

[RookTookIt]

I am against undergraduate shadowing. I shadowed as an undergrad before I had ever heard the word HIPAA. It was in a teaching hospital and I was introduced to the patients by the docs as "a student" which I'm sure they took to mean "a medical student". And after all is said and done, I don't think it really gave me any better of an idea about what it is to be a practicing physician.

I think that spending a few hours with a doc is great. It's useful to pick someone's brain especially about a profession that you are considering, but I have no idea why undergraduates (and younger!) need to be in the patient's room. We all know what that experience is like anyway because we've all been patients at some point.

 

[TheMightySmiter]

Would it be realistic for some sort of filtering process/application process to exist for shadows? I realize that most doctors are pretty open to having students observe. But they don't just take anyone off the street - in your guys' opinion, do you think that students are mostly respectful and trustworthy, or clueless?

A lot of hospitals do this already. I wanted to shadow a physician at a particular hospital in my home state, and I had to fill out an application and get approved. Then I had to go in and get a badge, and hand in proof of vaccinations and my recent TB test. The program probably didn't deny too many people who bothered to come in and apply, but at least the application process guaranteed a base level of commitment from those who wanted to shadow. I think it's appropriate for most hospitals to have a similar program.

 

[ucbsmd]

Where is the original letter? I can only see the responses.

Original
http://jama.ama-assn.org/content/305/10/1029.full

Replies
http://jama.ama-assn.org/content/305/23/2414.1.full
http://jama.ama-assn.org/content/305/23/2414.2.full
http://jama.ama-assn.org/content/305/23/2415.1.full

Response by Original Author
http://jama.ama-assn.org/content/305/23/2415.2.full

 

[NKChemEng]

A lot of hospitals do this already. I wanted to shadow a physician at a particular hospital in my home state, and I had to fill out an application and get approved. Then I had to go in and get a badge, and hand in proof of vaccinations and my recent TB test. The program probably didn't deny too many people who bothered to come in and apply, but at least the application process guaranteed a base level of commitment from those who wanted to shadow. I think it's appropriate for most hospitals to have a similar program.

That's good to know. If this was more widespread, I think this could help address the issues that physicians and patients have about the needed privacy in that relationship.

 

[eugenierose]

But they don't just take anyone off the street - in your guys' opinion, do you think that students are mostly respectful and trustworthy, or clueless?

They do, though. And they're clueless.

I think that spending a few hours with a doc is great. It's useful to pick someone's brain especially about a profession that you are considering, but I have no idea why undergraduates (and younger!) need to be in the patient's room. We all know what that experience is like anyway because we've all been patients at some point.

Agreed. Go sit and chat at Starbucks. A lot of schools are starting longitudinal clerkships in the 1st year which is basically sanctioned shadowing. A kind of pre-3rd-yr.

 

[RogueUnicorn]

+1 for clueless

 

[nebratu]

Where is the original letter? I can only see the responses.

previous issue. If you searcha JAMA for shadowing, should be the first or so hit

 

[tman5890]

+1 for clueless

👍

 

[Narmerguy]

I am against undergraduate shadowing. I shadowed as an undergrad before I had ever heard the word HIPAA. It was in a teaching hospital and I was introduced to the patients by the docs as "a student" which I'm sure they took to mean "a medical student". And after all is said and done, I don't think it really gave me any better of an idea about what it is to be a practicing physician.

I think that spending a few hours with a doc is great. It's useful to pick someone's brain especially about a profession that you are considering, but I have no idea why undergraduates (and younger!) need to be in the patient's room. We all know what that experience is like anyway because we've all been patients at some point.

Really? Are people sure that they're against shadowing entirely of if they're in favor of more regulation in what kind of shadowing is allowed? There's a big difference, because simply educating the shadowers and shadowees on a few things before the shadowing begins would solve the majority of the complaints (as well as making it clear to patients what their rights are).

 

[aSagacious]

"By not allowing college students to shadow physicians, some students' only opportunity to see what a physician does will be eliminated&#8212;and those who really need to experience this shadowing opportunity are women and underrepresented minority and underprivileged students." - Julie Ann Freischlag, MD (p. 2415)

Yes. Women and URMs are especially slow individuals and need extra experience before they are able to make educated decisions as to their career aspirations. 🙄

Do we really need these sorts of statements mixed into every opinion piece?

 

[a532]

The other problem she posits is that having a student shadowing can compromise the patient-physician relationship. The example given is say that the patient wants to ask the physician about sensitive issues such as HIV, homosexuality, etc. I would certainly not feel so comfortable talking about these topics with a student in the room observing me.

Definitely a valid point.

 

[ucbsmd]

The other problem she posits is that having a student shadowing can compromise the patient-physician relationship. The example given is say that the patient wants to ask the physician about sensitive issues such as HIV, homosexuality, etc. I would certainly not feel so comfortable talking about these topics with a student in the room observing me.

Definitely a valid point.

If your not comfortable you would probably just ask to speak to just the doctor.

 

[STAT EKG]

Really? Are people sure that they're against shadowing entirely of if they're in favor of more regulation in what kind of shadowing is allowed? There's a big difference, because simply educating the shadowers and shadowees on a few things before the shadowing begins would solve the majority of the complaints (as well as making it clear to patients what their rights are).

👍

 

[RookTookIt]

Really? Are people sure that they're against shadowing entirely of if they're in favor of more regulation in what kind of shadowing is allowed? There's a big difference, because simply educating the shadowers and shadowees on a few things before the shadowing begins would solve the majority of the complaints (as well as making it clear to patients what their rights are).

Maybe "against" is too strong a word. I just don't really see the benefit of it. I personally had very interesting shadowing opportunities, but I am sure that it was not a very valid way to choose if this was the correct career for me. I believe that I would have gotten far more out of simply having a conversation with physicians about their day-to-day. Given what I perceive to be a lack of benefit for the shadow, I think that any potential issues for the patient should be treated seriously.

 

[eugenierose]

"By not allowing college students to shadow physicians, some students’ only opportunity to see what a physician does will be eliminated—and those who really need to experience this shadowing opportunity are women and underrepresented minority and underprivileged students." - Julie Ann Freischlag, MD (p. 2415)

Yes. Women and URMs are especially slow individuals and need extra experience before they are able to make educated decisions as to their career aspirations. 🙄

Do we really need these sorts of statements mixed into every opinion piece?

That's her whole schtick.

 

[jhay]

Maybe "against" is too strong a word. I just don't really see the benefit of it. I personally had very interesting shadowing opportunities, but I am sure that it was not a very valid way to choose if this was the correct career for me. I believe that I would have gotten far more out of simply having a conversation with physicians about their day-to-day. Given what I perceive to be a lack of benefit for the shadow, I think that any potential issues for the patient should be treated seriously.

I hate to say it, but I strongly disagree with this.

Many things sound sweet and dandy until you experience them for yourselves.

 

[LizzyM]

I *loved* the "watch surgery on the internet" B.S. from Kitsis. As you know, watching a screen gives you the visual and perhaps the aural experience but if you are missing the olfactory experience of surgery, you are missing a lot.

 

[tartrate]

I *loved* the "watch surgery on the internet" B.S. from Kitsis. As you know, watching a screen gives you the visual and perhaps the aural experience but if you are missing the olfactory experience of surgery, you are missing a lot.

Hmm...perhaps you can put some meat on the stove to get the "whole" experience 😀

 

[eugenierose]

I *loved* the "watch surgery on the internet" B.S. from Kitsis. As you know, watching a screen gives you the visual and perhaps the aural experience but if you are missing the olfactory experience of surgery, you are missing a lot.

If you want to smell something awful, I'll send my brother over.

We don't call him Duke Nukem for nothing.

If it's blood or bar-b-que...

 

[n3xa]

I *loved* the "watch surgery on the internet" B.S. from Kitsis. As you know, watching a screen gives you the visual and perhaps the aural experience but if you are missing the olfactory experience of surgery, you are missing a lot.

I smelled. I clinically experienced. It was fantabulous.

 

[Astarael]

I can't read any of the letters, but I'm curious, do any of them address the fact that some patients actually enjoy having students involved? I know it's not a majority, but there were quite a few patients during my time shadowing that were pretty excited to be a part of the education of someone thinking about going into medicine.

 

[Narmerguy]

I can't read any of the letters, but I'm curious, do any of them address the fact that some patients actually enjoy having students involved? I know it's not a majority, but there were quite a few patients during my time shadowing that were pretty excited to be a part of the education of someone thinking about going into medicine.

Ah yes, I remember this being the case often when I shadowed. As a patient, I would find it pretty cool that I was being used as a case to educate a future doctor (what I would assume).

Truly, shadowing gave me a perspective of medicine that I could not reach any other way. Volunteering certainly doesn't give you that kind of exposure, and having an hour long cup of coffee with a physician will not give someone the understanding of what his day is like unless they have some frame of reference which--as an undergraduate student who has not worked a job, I do not have.

Like I mentioned, it doesn't seem like anyone has raised an argument against shadowing that couldn't be addressed with brief education and alerting patients as to what they do and do not have to put up with. The video idea is pretty absurd.

 

[LizzyM]

I agree that having the receptionist or nursing assistant say, "Dr. Duck has a student with him today. If you'd prefer not to have the student present, just let me know." would be a good way to go about it.

 

[NKChemEng]

i agree that having the receptionist or nursing assistant say, "dr. Duck has a student with him today. If you'd prefer not to have the student present, just let me know." would be a good way to go about it.

+1

 

[FlowRate]

My shadowing experiences came from:
volunteering jobs (already a credentialed, unpaid employee, trained in hipaa etc)
the university (they made sure we were hipaa trained)
personal doc

All of the docs I shadowed through these experiences either introduced me (volunteering related, as I'm already an employee) or asked if it was ok if I observed (university/personal doc related)

 

[doctorshateher]

I think that spending a few hours with a doc is great. It's useful to pick someone's brain especially about a profession that you are considering, but I have no idea why undergraduates (and younger!) need to be in the patient's room. We all know what that experience is like anyway because we've all been patients at some point.

While that is true, I would argue that most (not all, but most) undergrads have had a lot experience only with pediatricians/primary care docs and maybe emergency departments and a/or few others. And even then, their experience with the physician is often only the few minutes the physician spent with them.

As a patient you don't see what the doctor does before/after the consultation, you don't get to understand the pace of the work and you're not exposed to many different cases/patient types.

 

[doctorshateher]

"By not allowing college students to shadow physicians, some students’ only opportunity to see what a physician does will be eliminated—and those who really need to experience this shadowing opportunity are women and underrepresented minority and underprivileged students." - Julie Ann Freischlag, MD (p. 2415)

I guess I could understand this statement concerning underprivileged students because they might be less like to have been able to be seen by a physician as a patient when they were growing up.

Not really sure how it relates to women/URMS though...

 

[NYRN]

Nowadays with hospitals being very strict about patient privacy, I wouldn't be surprised if they banned shadowing altogether.

If this ever came to be, then private physician offices/clinics would be the only places left to shadow, which is good in some ways, but leaves out at least 50% of what a doctor does.

I have not seen students shadowing in my hospital, I'm assuming its not allowed. I have met several premed students who are volunteers, but they don't actually get to do much as far as interacting with the physicians, but they do get to interact with patients.

What I would propose is this:

Several hospitals are affiliated with universities. There should be a formal program set up between the school and the hospital that allows students to shadow several physicians in different specialties over a period of time, such as one semester or over the summer. The physicians would volunteer to do this so the shadower doesn't get stuck with people who don't like students lol
This experience would not be graded or anything, but the students would have to apply and be selected by an advisor to participate in this.

If this situation were reality, the wealth of experience the student would get by shadowing across different specialties would really give the student a picture of what different physicians do.

They already have similar programs over the summer for nursing students, I don't see why they couldn't do this with premed students.

 

[RookTookIt]

While that is true, I would argue that most (not all, but most) undergrads have had a lot experience only with pediatricians/primary care docs and maybe emergency departments and a/or few others. And even then, their experience with the physician is often only the few minutes the physician spent with them.

50% have also seen a gynecologist, many of seen ophthos or ENTs, but I get your point. Certainly you wouldn't have been exposed to many potential specialties, but I also only shadowed a couple of specialties (fewer than I have been a patient with). And that's another problem I have with shadowing -- it's to determine if you would like to be a "doctor" as if they're some cut-and-dry definition for the daily life of a doctor. There is no way you will be able to shadow all of the possible opportunities that a medical degree can afford you.

Anyway, I guess different people are into different things. For me, shadowing was fun and I feel like I got to do a bunch of cool stuff that I shouldn't have been able to do. Because of that, I was all like "Cool! Cool! Cool!" and medicine in general was MORE glorified for me after shadowing.

 

[Astarael]

Nowadays with hospitals being very strict about patient privacy, I wouldn't be surprised if they banned shadowing altogether.

If this ever came to be, then private physician offices/clinics would be the only places left to shadow, which is good in some ways, but leaves out at least 50% of what a doctor does.

I have not seen students shadowing in my hospital, I'm assuming its not allowed. I have met several premed students who are volunteers, but they don't actually get to do much as far as interacting with the physicians, but they do get to interact with patients.

What I would propose is this:

Several hospitals are affiliated with universities. There should be a formal program set up between the school and the hospital that allows students to shadow several physicians in different specialties over a period of time, such as one semester or over the summer. The physicians would volunteer to do this so the shadower doesn't get stuck with people who don't like students lol
This experience would not be graded or anything, but the students would have to apply and be selected by an advisor to participate in this.

If this situation were reality, the wealth of experience the student would get by shadowing across different specialties would really give the student a picture of what different physicians do.

They already have similar programs over the summer for nursing students, I don't see why they couldn't do this with premed students.

Good post 👍

There actually are programs like this. The one I know of specifically is associated with the volunteer department at a local hospital. Basically, the program has students do a 6 month volunteer rotation after which they are allowed to shadow a doctor (although I think the amount of shadowing in this particular program probably needs to be increased a bit). Overall though, it's a very good idea and could use some more people advocating for it.

 

[bucks2010]

tl;dr

In a clinic: have the asst ask patients if they're ok with a student being there

my best shadowing experiences have been in the OR - having a chance to see procedures has been invaluable. These opportunities should definitely be preserved.

 

[NYRN]

Good post 👍

There actually are programs like this. The one I know of specifically is associated with the volunteer department at a local hospital. Basically, the program has students do a 6 month volunteer rotation after which they are allowed to shadow a doctor (although I think the amount of shadowing in this particular program probably needs to be increased a bit). Overall though, it's a very good idea and could use some more people advocating for it.

I'm happy to see that these types of programs do exist, I think it is very important that a student, whether its a nursing student or pre-med is able to spend a day with someone in their respective profession. I can't comment on what type of experience it is as a premed with a physician, but I did a semester with an RN in the specialty of my choice when I was a senior and it really made me see nursing in real life as compared to my very structured clinical rotations.

If I were in charge of a formal pre-med program like I proposed earlier in this thread, I would design it in such a way that it can't turn into some sort of cutthroat competition and that by not participating in such a program offered at a particular school, it doesn't mean that the applicant isn't competitive. For example, everyone with a 3.2 or higher GPA qualifies, and upperclassmen get to go first because they have limited time left in school to do it. I think its safe to put the GPA cutoff at 3.2 because as a senior or even a junior that is ready to take the MCAT, they better have at least that GPA or med school may not be in their future at that point in time.

This type of opportunity would be mainly to observe, not to actually do much, and is not graded so that the student can relax during the rotations and just spend the time learning and observing.

As for the original article, I feel the right thing to do is for an assistant or the doctor to ask the patient in private whether he/she minds having a student observe. I would bet that most won't care, as long as the student isn't actually doing anything but observing and possibly assisting with simple tasks. I had a student once (I don't actually know if she was a medical student or a premed) observe me as a patient at my doctors office, the doctor asked me first and I said absolutely. These types of things don't bother me, but some people it might. This was also a GYN office and the student was female. I wouldn't have cared either way, but I can see how some women may have been uncomfortable if the student was male.

 

[Muntu]

Don't have a subscription so I can't read the articles but it seems like the main complaint is patients not being aware that the person who is observing them is a student. Seems like it's easily solved by having an assistant ask before the doctor comes in if it's ok to have the student come in as well. Personally for me, shadowing was invaluable. Despite growing up with a doctor as a father and having my fair share of doctor's visits, being able step to the other side and see how things happen from the doctor's point of view taught me quite a bit and helped me really see what kind work it really is. If I didn't get that chance until I way later down the line and realized that it wasn't for me I would be really pissed at myself for wasting all that time.

 

[AsianPersuasion]

When I was shadowing the trauma surgeon he would introduce me as his "fearless student" to all the patients and I'm pretty sure all the patients thought I was a med student.

Anyways, a lot of them seemed OK with it and actually enjoyed having students around. Like others have posted experiencing surgery in OR was the best part. 👍

 

[Nomdeplume]

I *loved* the "watch surgery on the internet" B.S. from Kitsis. As you know, watching a screen gives you the visual and perhaps the aural experience but if you are missing the olfactory experience of surgery, you are missing a lot.

So true. If you spend four years of undergrad and two years of medical school thinking that you're a perfect fit for surgery, and then you learn that the smell of electrocautery nauseates you, you're in a spot of trouble.

In terms of patient privacy, I have never thought of undergraduate shadowing as being much different from the rotations that medical students do. This kind of exposure to the actual practice of medicine is arguably the single most important aspect of a medical education. In my experience, I have only ever once observed a patient who did not explicitly consent to it, and that patient was afflicted with dementia and presented to an emergency room. Similarly, a handful of patients have politely asked that I not be present, which was a request I was happy to oblige (also, the doctor immediately booted me ).

I agree with the idea that there are "right" and "wrong" ways for shadowing to happen. Informed consent of the patient is definitely important. But this type of clinical experience is crucial to medical education at the higher levels of the game, and I think it's nearly just as crucial at the undergraduate level.

Medicine is one of the most expensive careers I can think of. It can cost as much as $300,000 or more if you include undergraduate costs and, more importantly, 5 to 9+ years of the student's life. Preventing students from seeing what they're getting into sounds ridiculous to me. I certainly wouldn't feel comfortable taking that leap without some real experience with what the result would be, especially when I could enter a much cheaper career with ridiculously faster training at the drop of a hat. Shadowing made all the difference to me.