Is physician shadowing harmful for patients?

I was startled to learn, when interviewing medical school applicants, that tagging along with a physician, or “shadowing,” is a common practice among high school and college students these days. Yes, I did say students as young as high schoolers.

Shadowing provides a way for students to observe at first hand what it is like to be a physician, and helps them decide whether the career will suit them. Medical school admissions committees look for activities such as shadowing as evidence that applicants have been exposed to medical settings, as confirmation both of students’ interest in medicine and of their understanding of the life of a physician.

But as I spoke with premed after premed about their shadowing experiences, I became uneasy.

As a physician and a bioethicist, I started to wonder whether shadowing—while helpful for students and admissions committees—might potentially be harmful for patients.

The first time my ethical antennae were raised was when an applicant described his experience shadowing a gynecologist. I asked him whether any patients were reticent about having him in the exam room. He said no, but mentioned that he did feel a little awkward that the gynecologist introduced him to patients as a “student doctor,” and then let him watch them undergo pelvic exams. I wondered (to myself) whether these patients would have allowed the student to watch had they known he was a college student trying to decide about his career.

My curiosity about that question led me to examine the issue further. Just how does such a process fit into medicine, and what does it mean for doctors and patients? I examined shadowing in depth along with Michelle Goldsammler, M.D., in our paper “Physician Shadowing: A Review of the Literature and Proposal for Guidelines,” which was published in the January 2013 edition of Academic Medicine. Our goals in the paper were to review the literature to find out whether shadowing is effective, look at the ethical issues connected to it and figure out why people shadow physicians.

What we found troubled me. Of 770 articles in the literature from 1948 to 2011, we could find only 13 that specifically met our criteria for inclusion in the study, and only two of those examined shadowing exclusively. We concluded that more research is warranted and that objective outcomes would be useful. Guidelines on shadowing are needed and a code of conduct needs to be introduced for premed students to enhance consistency in shadowing and ensure that ethical and practical considerations are addressed.

Of course, there are other ways to find out what it is like to have a career in medicine. I know this because shadowing was not done in the Paleolithic age when I was in college. My exposure to medicine was primarily through my father, who was an ophthalmologist. I was keenly aware of his dedication to and love of his work, and impressed by the patients who came up to him in restaurants and stores to seize his hand and thank him for restoring their sight. I never witnessed him interacting with patients, though; I never followed him into the exam room. Maybe I was lucky; not everyone has a relative in medicine. To see doctors up close, I worked in the occupational therapy center of a psychiatric hospital, and participated in basic science and clinical research. I also was a candy striper. What’s a “candy striper?” you may ask. It’s a hospital volunteer from another era—but that’s a blog post for another time.

As far as physician shadowing goes, I have misgivings. I wonder whether patients are actually aware that high school or college students are present during their appointments with their physicians. Are the patients given the chance to decline? Even if given this opportunity, does the power imbalance in the physician-patient relationship inhibit them from saying no for fear of irritating their doctors? And if they do allow students into the room, do they share medically important but sensitive information? Might they neglect to mention rectal bleeding because they feel embarrassed at the thought of having a high school or college student present during a rectal exam? Do they omit discussing a concern about having contracted a sexually transmitted disease? Or not answer honestly about their alcohol consumption? Are these concerns outweighed by the benefit derived by premed students from being in the room? I suspect that students would respond in the affirmative.

But I am not sure what patients would say.

Have you ever shadowed a doctor as a premed or high school student? Did you find it useful? As a patient, has shadowing ever made you feel uncomfortable?

Elizabeth Kitsis is Director of Bioethics Education and Assistant Professor of Medicine, Albert Einstein College of Medicine. She blogs at The Doctor’s Tablet.

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