Declining care from physicians in training

Recently, I had the fortune of hearing the tale of Bob and his bum knee.

It all started when Bob picked me up at the end of a busy clinic day in his neon orange Subaru.  Given that this particular shared car service promotes friendly conversation, Bob started up the gab by asking me what position I held in the medical center.  After describing my work as a resident physician in internal medicine, Bob nodded in acknowledgment and began to tell his story.

The setup

Bob commenced this unsolicited anecdote with a description of his days back in Oconomowoc, WI, just before the recession hit nationwide.  After only a short time looking for a job, Bob received what he described as a decent offer to work in marketing.  Given the fact that his mother was ill and he had ultimate plans to move out west, he decided to pass up on the offer and wait a few more months before reentering the workforce.

The rest of Bob’s story unraveled like a made-for-TV movie: his mother’s health declined sooner than anticipated and, sans employment in the midst of the market crisis, he ultimately forged ahead to San Francisco.  After several months of odd jobs in construction and landscaping, Bob noticed one of his knees swell “to the size of a basketball” and was no longer able to support himself given the new disability.  Given his lack of health insurance, he went to the county hospital for further workup of his knee.

Here is when my ears started to prick up.

He went on to describe how a young woman, identifying herself as a resident physician, had him change into a gown and reveal the swollen joint.  After preliminary imaging and a thorough examination, the resident explained to Bob that the knee would have to be drained and likely injected with an anti-inflammatory medication.  She described the risks and benefits of the procedure, had Bob sign a consent form and began preparing the clinic room for the minor procedure.

Bob, unaccustomed to playing the role of a patient in any hospital let alone a teaching hospital, was unfamiliar of the resident title and unaware of the significance it had in the spectrum of clinical training.  Through further questioning, he soon discovered that this physician was only a few years out of medical school and had done only a handful of this type of knee procedure.  Upon realizing this, he politely asked to postpone the procedure until a more experienced physician was available.  Several hours later, a supervising physician drained Bob’s knee, and he was discharged with a “brand new life.”

Bob made sure to throw two thumbs up as he revealed the well-healed knee to me before driving off to his next customer.

The conflict

Well after seeing the last of Bob and his bum knee, his story stuck with me.  At first I was angry over Bob’s decision to deny care from a capable physician in training.  I won’t lie that I briefly felt that Bob’s lack of insurance and admission to a teaching hospital waived his right to make the demands he had made.

But then I thought about Bob’s situation.  Here’s a guy who could not afford an operator error on his injured knee given that he was living from paycheck to paycheck off physical labor.  He had no experience with teaching hospitals and little understanding of the role of a resident physician.  Furthermore, his insurance status should have had no place in limiting what questions and concerns he could voice with regard to his treatment.  His decision to receive the most skilled care he could get was understandable.

And here lies the resident’s dilemma: If all patients had the same resolution to bypass care from physicians in training, how are newly-minted doctors able to sufficiently train in clinical medicine?

What steps can be made to close the communication gap between patients unaccustomed to teaching hospitals and the house staff (resident and intern physicians) who care for them?

The solution

There is undeniable room for improved communication when it comes to defining roles and setting expectations on how care is delivered in a teaching hospital.

To start, every member of a newly admitted patient’s health care team should introduce themselves and their distinct roles as health care providers as early as possible in the patient’s hospital stay.

There are often many members of a health care team in a teaching hospital and it is not uncommon for patients to get confused over titles and levels of medical expertise.  The team should therefore write their names and roles on any available board in the patient’s room and/or give out business cards to ensure transparency.   Patient concerns about the level of training and clinical experience of providers should be answered as early as possible.

For patients like Bob who have little experience with teaching hospitals, there may be a need for additional educational interventions such as pamphlets or brief educational videos describing the fundamental role that resident physicians and medical students will play in their care prior to meeting the medical team.

Take home point

Should I ever have the opportunity to ride with Bob again, I plan to ask him a few questions: If he was notified that he was in a teaching hospital prior to meeting the resident physician, would he be have been more amenable to having the procedure done by her?  Does he plan to avoid teaching hospitals from now on knowing that most of the physicians are in the midst of their medical training?  If he had to be treated by a team that included residents and medical students, what would make him most comfortable with the way his care was delivered?

In order to mitigate tales similar to Bob and his bum knee, teaching hospitals need to be more cognizant of the potential disconnect between patient expectations of care delivery and house staff need to provide direct patient care.

*The patient’s demographic information in this article was changed to protect identity and assure anonymity.

Brian J. Secemsky is an internal medicine resident who blogs at the Huffington Post.  He can be reached on Twitter @BrianSecemskyMD and his self-titled site, Brian Secemsky MD. This article was originally written for the American Resident Project.

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  • Ron Smith

    Hi, Brian.

    Interesting article. I wonder too if you might ask Bob if he thought that he actually might be getting even better care from that resident physician?

    The challenge of plowing through the vast seas of knowledge for a resident is similar to what an old thirty-year veteran codger like myself experiences. Residents I think tend to be quick to learn, but a little to quick to accept everything at face value. For physicians on my end of a medical career, that tends to be reversed.

    I guess that’s why wife says I’m a codger! ;-)

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • NewMexicoRam

    I was a medical student and resident from 1982-1989.
    If I had needed medical care during those days, I would have felt very comfortable placing myself under the care of my attending residents and fellow residents.
    And may I add, reverting back to the article, I really do not see how the suggested approach would make any difference.

    • EmilyAnon

      But your confidence was based on that you knew the residents and observed them in action, probably stood next to them in the operating room and saw what they were capable of doing. I would be comfortable too being in the care of a star resident if I had that first hand knowledge, but the general patient doesn’t. We are asked to blindly trust.

      Of course it’s obvious that trainees have to train on real patients, and I accept that this is how the system works, but it’s kind of hard to believe that the care from a beginning surgical resident about to embark on his first operation will be the same quality as delivered by a senior resident with many operations under his belt. As we don’t know if we are to be that first patient, can’t you understand why this makes us a little nervous.

      • guest

        It makes me a little nervous to let my teenagers drive by themselves, when they first get their licenses. But it needs to be done, or they won’t be able to grow up and drive independently.

        As has been mentioned elsewhere, there are lots of hospitals which do not have residency training programs, and patients who are too anxious about having residents involved in their care should definitely make sure they go to those hospitals instead of teaching hospitals

        • EmilyAnon

          Where in my post did I mention that I didn’t want trainees in my care. I ackowledged the importance of training in the second paragraph. And why is there always the predictable, knee-jerk response to tell the patient to go elsewhere if they have questions about the skill level of people in their care. Is it none of our business?

          • guest

            See my response above about just this question.

          • EmilyAnon

            It didn’t address anything I wrote. Unless you’re implying that patients have no right to know the experience or skill level of their providers.

          • guest

            As I said above, when I go to the lawyers, or the mechanics, or the hair salon, I do not expect that I am going to be informed about such matters. And if I started to make a habit of asking, I would be perceived as a difficult customer. Furthermore, why would I ask? Since realistically I am not going to be able to demand that the master mechanic work on my car, how is it going to help me to know that the apprentice is going to be doing a lot of the work?

          • jurisrn

            Well, I don’t know about your garage, but I promise you that you would be informed at your lawyer’s office. I never had an encounter with a client that didn’t begin with my status ad a student clerk.

      • NewMexicoRam

        And how did that senior resident get his experience? By waiting to do his first procedures until he was a senior resident? Hardly.
        Everyone wants their life to be lived out with a guarantee. That’s not realistic. 100 years from now, it will not matter if a first year resident or an attending with 30 years experience did your procedure.

        • EmilyAnon

          My reply to you was to differentiate your comfort level with trainee care with mine. You know in advance the skill level of any trainees who will be in your care, or at least have the privilege to vet them beforehand. And I’m sure you have the option to exclude any trainee that doesn’t meet your standards. Outsiders don’t. I don’t resent this insider “perk”. Anybody would take advantage of it.
          And once again, I never said in any of my comments that I would refuse trainee care.

          • NewMexicoRam

            I understand what your argument was. You brought up that a senior resident has more experience. I agree. And how did that resident gain his experience? That was my question.
            And I didn’t say that I believe you would turn down trainee care. If you are not comfortable with residents’ care, fine. But someone, somewhere, has to be comfortable with it or we wouldn’t have experienced doctors.

          • EmilyAnon

            The doctors’ responses here are appreciated. Thanks to you and ‘guest’.

        • Observer

          But in the meantime, it does matter to me while I’m alive. I have no problem letting a newbie try out minor (to me) procedures on me, but I will not be consenting any more to being a guinea pig for more significant (to me) ones since I feel I’ve done my duty for the cause of medical education by having a resident botch my colonoscopy (the fourth one he botched, zero successfully completed). I absolutely empathize with someone else who might wish to decline to allow their bodily integrity to be put at risk in that way in the first place.

          • VanessaObRN

            The chance of collateral damage is an unfortunate reality with physician training. Making and correcting mistakes is a necessary component to learning. Your sacrifice is not wasted.

          • rbthe4th2

            How about for those of us sacrificing our lives? That’s acceptable?
            Randy

          • DoubtfulGuest

            If I may jump in here, I accept that risk of collateral damage and I am happy to let medical trainees at all levels be involved in all aspects of my care. Not uncommonly, doctors at any point in the hierarchy neglect the “correcting mistakes” part. How can we change that? My bad experience was with an attending at a different teaching hospital than I go to now, and also with a specialist in private practice. I like students and residents, never had a problem with any of them.

          • NewMexicoRam

            That’s fine. You have that right. I’m just saying that experience only comes one way.

            Oh, may I add that during my training as a resident, we had one botched infant circumcision at my hospital: An attending with more than 10 years of practice experience cut the glans off a newborn. The residents, with less experience, and more fear, took more time with the procedure and never had a mistake.

            It goes both ways. Again, no one is perfect but gaining the experience really helps.

  • JR

    Until I started following this blog, I thought “resident” meant “doctor hired by a hospital to work at the hospital rather than work in a private practice.” I had no idea it meant apprentice/intern/student in training working under a doctor’s supervision.

    • guest

      A resident is not a student. A resident is a doctor who has completed his or her medical training, and is an M.D. With an M.D. you are able to practice medicine independently, but almost all M.D.s elect to do a residency for further training in their specialty, after they graduate from medical school.

      • JR

        Every doctor I know considers residency a part of their training. Residents are doctor apprentices or doctor journeymen – those who are still learning their craft through experience rather than through school.

        “Medical Student” is a term that is used in the medical industry to mean something specific, but outside the medical industry anyone learning anything is a “student”. So to those outside the medical industry, residents are students. Sure, maybe “journeyman” is a better term, but we’re just arguing terminology at that point.

        Even if a few people refuse to be seen at teaching hospitals, that won’t leave a shortage of patients at all. Teaching hospitals only see about 1% of overall patients at any given time. (Source:)
        http://www.kevinmd.com/blog/2013/05/training-physicians-care-1.html.

        • guest

          I think you are drawing a distinction that is perhaps made in the trades, but not in the professions. In medicine, law and banking, once you have earned your degree, you are a doctor, a lawyer, or a banker. In law, you are a “first year associate” and closely supervised by your seniors. It’s the same in banking. In medicine, you are an intern. The difference is that not too many of us interact with lawyers and bankers on a regular basis, and so it’s only doctors that the public generally sees progressing through their careers in this fashion. Nonetheless, residents are not “students.”

          People who feel that they should only be interacting with the most senior people in the profession are welcome to go to non-teaching hospitals and see how those doctors are.

          • JR

            In business, experience is very important. That’s why job descriptions say “3 – 5 years experience” on them. Software Development is an example of a profession that takes 10 years to learn to be proficient, hence, we have Jr. Developers, and Sr. Developers who each have different roles, with the Sr. Developers mentoring the Jr. ones.

            And don’t think lives aren’t at stake with software. My current car mechanic got tired of doing nothing but software upgrades at his last job, he wanted to do “real mechanic work”.

            I’ve been to community hospitals twice, and teaching institutions twice. That’s a total of four hospitals, one of each as a child, one of each as an adult. Hands down I received better care at the community hospitals. So if I need care in the future I’ll go there.

            Why does that bother you that someone is making a choice in their care that suits their needs?

          • guest

            As I am an attending at a teaching hospital, I would vastly prefer that a patient who was not comfortable having residents involved in his care, go to the community hospital. As you mention, we have plenty of patients, and we are certainly fine with people going elsewhere, if they have the option.

          • guest

            My personal opinion is that if you have a common condition (and I appreciate most people do not know their diagnosis ahead of time) the community hospital is a fine place to be. You’ll likely get a surgeon who’s done thousands of these procedures. I scratch my head in disbelief when I see patients come for their unusual conditions to the community. The unusual cerebral aneurysm, spinal tumor, pheochromocytoma is better managed at a teaching hospital IMO. Just my 0.02

  • John C. Key MD

    This is definitely not a new issue at all. As a surgical resident in the 1970′s I recall a “60 Minutes” presentation that sensationalized the story that incompletely trained residents did all the surgery while the attendings were on the golf course–complete with video to support. We faced lots of tough questions from patients for weeks.

    I really don’t have any sympathy for anything less than a full-throated defense of the residency system; this defense should consist of confident communication and explanation. And no apology for it.

    As one of my staff men used to say, “This is a teaching hospital–we’ll teach the bastards to come here!” Patients who decline to participate are free to go elsewhere.

    • guest

      Yep.

    • JR

      Not all patients have a choice (or are aware there are choices) when it comes to medical institutions. I ended up at an emergency room at a teaching institution because it was the closest hospital at the time.

      Now that I know I have a preference, I’ll excuse myself from teaching institutions and go to a non-teaching institution in the future.

      Unfortunately, this means that teaching hospitals will end up with patients who did not choose to go there, and their wishes need to be respected even if it’s inconvenient. Studies show most people will allow students to participate in their care when asked.

      • guest

        Actually, a lot of patients, myself included, elect to go to teaching hospitals for our care, because we know that the fact that the institution is a teaching program means that all doctors there will be more current in their medical knowledge and skills.

        • JR

          It’s nice that you’re a good fit for a teaching hospital. I know a lot of people are fine with that and I respect their decisions.

          It still doesn’t mean all patients are a good fit, and not all patients have a choice on where they go. If all patients who went to a teaching hospital were fully informed and wanted to be there, we wouldn’t have anything to discuss.

          • guest

            Patients who have no choice on where they go, are generally in the position of having Medicaid or no insurance. Medicaid (and actually Medicare) payments are structured to account for a care delivery model in which lower-cost care is provided via residents who are being supervised by an attending.

            To a certain extent, I am of the opinion that if you are at a public hospital, you should not be asking for special exceptions to be made to provide you with other than usual care. Naturally, it is important for patients to be informed about students being involved in their care. But residents are doctors, and I am not sure that it’s really useful to go into a lot of detail about first-year versus third year residents, since it’s not possible for the system to guarantee that everyone who asks would be able to be cared for by a third-year resident or an attending.

          • JR

            As I stated:

            I went to a teaching hospital solely because it was the closest hospital nearby. My health insurance at the time was top-notch. I had no idea it was a teaching hospital, or that choices between teaching vs. non-teaching hospitals existed.

            Now that I’m informed, I can make an informed choice.

            I see doctors on social media constantly state that patients choose to come to a teaching hospital, therefore, they need to suck it up and deal with it.

            But they are wrong.

            Most patients don’t make a choice to go to a teaching hospital, they just end up at one. That’s my point, the public is not informed so it’s not an informed choice.

          • guest

            I personally see no need for the public to be informed about whether they are being seen by a first year versus a third year resident.

            The intern is less experienced than the third year resident, who is less experienced than the attending. However, they are all doctors.

            When I take my car to the mechanic, I have no idea if it’s being worked on by the master mechanic or his helper. When I call a salon for an appointment to get my hair cut, I have no way of finding out if the operator I get booked with is the most clumsy operator at the salon. When I hire a contractor, there is no guarantee that every member of his crew will have years of experience. The one time I used a lawyer, the partner handling my case did not explicitly state that his associate, who was handling some of the details of the case, was a first-year associate.

            With all of these experiences, I suppose you could say I was not being given the opportunity to “make an informed choice,” since I am sure that if I started asking questions or demanding a certain level of experience, people would think I was crazy, or difficult, or both. Actually, in the case of the lawyer, when the first-year associate told me something I thought was incorrect, I asked to speak with the partner. I expected, and got, a large bill for the 5 minutes he spent on the phone with me.

            My point here is that I think that medicine is being held to a different, and totally unrealistic standard of behavior than any other profession or occupation, and it’s not sustainable, since to fulfill some of these demands requires resources that no one wants to pay for.

          • JR

            I don’t see the difference between asking for a lawyer’s supervisor, and asking for a resident’s supervisor.

            People ask for supervisors all the time every day. Every business has to deal with customers demanding to speak to someone else. Every single one.

            Of course, it would be a problem if all customers demanded to be served by supervisors, but they don’t. Most people are happy to be served by whoever they get.

            Of course, in any other business other than a lawyer, talking to a supervisor doesn’t net an extra bill either.

          • guest

            I don’t think there’s an issue at all with the patient asking to speak with the attending if there’s a problem.

            I think the issue is that, just as I wouldn’t expect to be told by the mechanic when I drop my car off “By, the way, Brian who has only been working here for one year will be working on your car, not the owner of the garage,” I am not sure it’s reasonable for patients to expect that their contacts with doctors in the hospital be prefaced by explanations about how long the doctor has been a doctor.

            And there is definitely an issue, in my opinion, with a patient like the one above, who goes to the public hospital for free care and then demands that a resident not do his procedure. I notice that Dr. Secemsky is adopting a fairly permissive stance about this sort of behavior and writing about how patients should get brochures. Actually a brochure is a marvelous idea and I think it would be very useful to patients and doctors alike. Maybe Dr. Secemsky should write one, since he appears to have a strong interest in patients being better informed…

          • JR

            Wow, so you think that patients who can’t pay for their care should have no say in their care?

          • guest

            I certainly think they have the right to refuse to have the procedure done at the public hospital. I am not so sure I think they have the right to demand that an attending do their procedure.

            You mentioned beauty schools. If I went to a beauty school to get my hair cut by a student, I would not have the right to get there and then demand that the student go away and my hair be cut by an instructor instead.

          • JR

            But you would go to a beauty school with the intent of having a student cut your hair.

            People who go to teaching hospitals don’t always know they are at a teaching hospital.

          • guest

            Right, so I agree that an educational brochure would be very useful, and that someone should write one.

          • JR

            What I said was: patients shouldn’t be treated badly if they end up at a teaching hospital and ask not to be treated by students.

            The hospital I went to was called “Person’s Name Hospital” and no where on their website do they list they are a teaching hospital outside of their “employment” section. So no – not all hospitals advertise this.

            Bob clearly had no problem being seen by a resident until he needed a specific procedure done. When he needed that procedure done, he did what most reasonable people would do: he asked how many times the resident had done the procedure. Which was not very often.

            So to the garage story: Do I care if someone has only changed the oil in a car once or twice before they change mine? No, it’s just an oil change. If my car had been in a wreck and needed the body repaired, you bet I’m going to ask a lot of questions. If the mechanic had never done body work before, or only done it a few times, I might take my car somewhere else. I don’t think that’s unreasonable at all.

            Frankly, I’m really not interested in whatever points you’re trying to make that have nothing to do with my point. My point is:

            Patients end up at teaching institutions without wanting to be there. When it happens, treat them well regardless.

          • DoubtfulGuest

            The info really should be on their websites. Signs and posters in each department might help, too.

          • JR

            I think my other comment was eaten so:

            I am not arguing that I prefer a third year student vs. an intern.

            I am arguing that not all people choose teaching hospitals or are even aware they are at teaching hospitals or know they have a choice. So you will get some patients refusing care by students, interns, and residents. Just like some customers demand to speak to a manager straight off. Most the time, you don’t get charged extra for speaking to a manager.

            A customer certainly knows the difference between going to a beauty school and going to a salon. A customer knows the difference between taking your car to high school garage and going to a mechanic.

            Some 60% of people have a fear of having their blood drawn. I really could care less about having my blood drawn, so when I was asked if a student could participate in my blood draw a few weeks ago I was glad to participate.

            I will never go to a teaching hospital ever again.
            Nothing you say can change my personal experiences. Been there, done that, never again.

            But my point still stands:
            Patients have a right to know they can refuse to be admitted to a teaching hospital and go somewhere else instead should they choose. And they have just as much right to “ask to see a manager” as a customer at a fast food joint.

  • John C. Key MD

    Regrettably there aren’t many 100%s in medicine. Residents are rarely the unattached, unsupervised loose cannons you portray them to be. Senior staff can make mistakes and fail just as easily or more so. Just one more reason it is referred to as “practicing” medicine. Takes a lot of practice.

  • guest

    This is a tough one! I know I learned procedures by doing them on my own; often the attending was a private physician either at his/her office or God knows where. I kind of shudder to think back to the days I “practiced” on patients when I was less than 1 year out of medical school. However, had I not done procedures on my own I never would have learned how to do them or become adept as I am now.

    I don’t have issue with residents or fellows assisting. But I have stated before that I would not want a trainee doing my procedure or my child’s procedure. So how do they learn? Who deserves the experienced practitioner and who deserves the trainee? How does one become experienced without practicing, trying, making mistakes?

  • FEDUP MD

    When I had my own surgery, I went to a teaching hospital. Why? I knew that the number of people looking after me would be higher and there would be more checks and balances. When I complained of postop bleeding that could have been a sign of a serious issue, I had an intern bedside in 3 minutes and a chief resident in less than 5, all trained in postop care. Good luck getting that level of response at a community hospital, where the attending is home at night and in clinic or OR all day and relies only on the nurse’s reports. I felt much better knowing that a 5th year resident was calling the attending rather than a nurse, especially considering the chief resident could potentially have started an emergency surgical intervention to save my life if necessary as the attending drove in.

    I am also leery of people who go to a teaching hospital and then demand no learners. I have in the past explained that this is actually less safe, for some of the reasons listed above. Also, the system is set up for safety in a certain hierarchy, so that it is always clear who answers to whom. If a nurse has to keep track of call the intern for Mr. x but call attending Y for Ms. m but attending Z for Mr. k, it invites errors in the system which
    can lead to significant delays in care. Especially considering the system in a teaching hospital is set up typically in a fashion such that attendings are expected to be able to do a lot more clinic and OR time due to the presence of residents to do the grunt work like writing Tylenol orders and laxatives. If the nurse is waiting for a call back directly from an attending for these, you as a patient are likely going to be waiting a lot longer for these, which doesn’t help to quality of your care. Nor would you be happy if you were the patient in clinic having the doc pulled out of the room constantly for these types of things.

  • FEDUP MD

    So I am unclear. The residents won’t go to the mat arguing a zebra when the attending thinks it is a horse. So they weren’t there, the attending would think it was a horse anyways, maybe even without someone putting any mention of a zebra at the back of their mind. I don’t understand why the second scenario is not worse.

    My experience has been residents help attendings by constantly questioning them. Sometimes residents ask me questions which make me think of the situation in a different way, and make me better think through my clinical reasoning. Overall having them involved improves the care I am able to give.

    • DoubtfulGuest

      This has been my experience, too, on the receiving end of care.

  • Mengles

    Yawn. This is not a suddenly new issue. It’s been the case since the beginning of residency. Simple problem, simple solution.

  • Mengles

    Simple solution: Get private insurance and go to a NON-teaching hospital. Until then, tough.

  • buzzkillersmith

    1. If you don’t like med students and residents, go to a community hospital. This works for most stuff, probably not lung transplants and such.

    2. In the old days we spent a lot of training time at the VA and at county hospital, both affiliated with the med schools of course. The vets didn’t complain. Heck, a good number of them had altered mental status. When you went there you could be a “cowboy.” I drained knees and did spinal taps and pleural taps and belly taps and put lines into people’s jugular veins as a third-year med student. Sometimes with 4 hours of sleep in the past 36 . The pts did OK, at least as far as I know. The old mantra was see one, do one, teach one. Not sure if that flies these days.

    3. Sometimes we would go days at a time without seeing a senior physician at the VA. More often at county, at least in pediatrics and obstetrics. That was probably a good thing. I kinda miss those days.

    4. The university hospital was not that fun. Too many rules.

  • Teresa Brown

    I don’t mind receiving care from physicians in training, as long as it’s not for something major. I recently needed complex orthopedic surgery, and there was a resident involved in part of the surgery, but the attending made sure to tell me that he would be doing the bulk of the surgery. I declined an H&P from a med student at one of my appointments with my gyn/onc. My doc asked me first and said, “Don’t feel obligated to agree to this.” I said I’d prefer not to do it. She doesn’t usually have students in her office, so it was kind of surprising to be asked. I almost always say no to PA/NP students.

  • Ed

    I would love to see this scenario play out in the court of public opinion (and real court): A teaching hospital turns away a seriously ill/injured patient, with or without insurance, because they had the audacity to question/refuse student participation. Attorneys would have a ball with this one!