Virtual Mentor. December 2003, Volume 5, Number 12.
Student Role in Discussion of Diagnosis with Patients
Medical students who are aware of information regarding a patient's prognosis are not at liberty to share the information with the patient, even if asked directly.
Commentary by Mary Oliver and Mary Ann Hopkins, MD
Neil is a fourth-year student completing his surgery subinternship at a private teaching hospital. He has been on the service nearly a month and follows 6 patients, visiting and examining them in the mornings and writing their daily progress notes. One of his patients this week is a retired lab technician named Alan, who had a bowel resection for colon cancer 2 years earlier performed by one of the attending surgeons on Neil's surgery team. Alan's lymph nodes had been negative at the time of surgery, and he was told that he was essentially "cured" of the colon cancer. He has felt well since recovering from surgery, except for some shortness of breath over the last month or so. Two days ago, Alan developed a fever and worsening shortness of breath, so he came to the emergency room and was admitted for what looked like pneumonia on a chest x-ray. Alan was pleasant and chatty with Neil during Neil's visits to his hospital room and often expressed his desire to "get over this cold and get back out on the golf course."
One morning, as Neil was writing his notes and looking up lab results, he read that Alan's chest CT showed multiple soft tissue masses in the right and left lung consistent with metastatic colon cancer. Neil's heart sank as he reviewed the CT report, knowing that the prognosis was going to be grim for Alan.
After finishing with his responsibilities on the floor, Neil generally joined the surgeons and residents in the operating room downstairs and discussed any abnormal lab findings or new pathology or radiology reports. As Neil approached the elevator, Alan stepped out of his room and said, "Um, excuse me Doc, I just spoke to a buddy of mine down in radiology, and he said that the reading was in on my chest CT from last night—what's the word on this pneumonia of mine?"
To Tell or Not To Tell
This scenario, in which a student is asked by a patient to disclose complex diagnostic and prognostic information, is not uncommon in teaching hospitals. In this case, it seems that Neil has gotten to know Alan well, perhaps better than the residents on the team. Students often have ample time to spend getting to know their patients, as clinical clerkship hours are generously allocated to promote extensive patient-student interaction. During sessions with patients discussing their concerns, hearing their stories, and joking about the terrible hospital food, positive rapport readily develops. This relationship is a valuable asset to the medical team. Medical students are often the first to be aware of changes in the patient's condition or work-up either by prerounding, seeing a patient throughout the day, or checking labs and imaging reports. Conveying this information to the rest of the team can facilitate the implementation of appropriate changes in the patient's treatment plan.
The role of a student as a conduit for information from patient to attending physician is clearly defined and easy to execute. Conversely, the role that a student should play in communicating complex information to patients about the mechanism of a disease or the intricacies of a treatment regimen is less clear. Students may be able to provide answers to simple questions with confidence. On the other hand, how they should respond when asked more difficult questions is unclear. Students' lack of knowledge or experience and their doubts about whether withholding information from a patient violates the standard of honesty expected in patient-physician interactions may cloud the issue.
A brief review of some key principles of ethical decision making provides insight in determining a student's role in discussions about diagnosis and treatment. Consider a central tenet of medical ethics; "a physician must recognize responsibility to patients first and foremost" . As part of this responsibility, "physicians must be honest with their patients and empower them to make informed decisions about their treatment" . Physicians are compelled to provide accurate and honest information to patients, enabling patients to exercise their rights to autonomy.
Consistent with this central dogma of medical ethics, a student's actions should be guided by the patient's best interest. Reflecting on the scenario involving Neil and Alan, recall that the CT scan was consistent with metastatic colon cancer. Neil correctly recognizes that this is a much worse prognosis than an uncomplicated pneumonia, but he has not yet discussed the results with the rest of his team. Assuming that Neil has not had previous training in colorectal cancer, it is unlikely that he would be able to provide the patient with extensive information about the implications of this diagnosis or be able to discuss details about further diagnostic work-up, therapeutic options, and prognosis. It is the student's responsibility to confirm that the information he provides to his patient is both accurate and complete. For this reason, it is imperative that the case first be discussed with senior members of the team before Neil speaks with the patient, so that complete and correct information can be compiled to share with the patient.
In this clinical case, there are additional factors that support a decision by the student to postpone revealing the imaging results. The psychological implications of the diagnosis are significant. Out of respect and compassion for the patient, one must identify an appropriate environment in which to deliver bad news. This type of conversation should not occur in a hallway, where there is little control over the privacy of the exchange. Also, an ample amount of time should be allotted for the discussion. It would be cruel to report a devastating diagnosis to a patient and then step onto an elevator, leaving him without emotional support. Another important factor for a student to consider is the perspective of the attending physician treating the patient. A relationship exists between the physician and the patient that must be respected. The attending assumes the ultimate responsibility for the patient's care; students and residents working with the attending physician should be aware of their disclosure of sensitive information to their patients.
Two major points support the decision of a student to withhold information from a patient: lack of knowledge and experience and an inappropriate environment. This does not resolve, however, the troubling issue of one's responsibility to be honest. Honesty implies integrity, truthfulness, and freedom from deceit. Given that Neil should not engage in a discussion about diagnosis with Alan for the reasons previously mentioned, can Neil be honest with Alan in response to a direct question? Does Neil have to lie about his awareness of the test results? By acknowledging that the information requested is available and explaining to the patient the reason for momentarily withholding the information (ie, it must be first discussed with the attending for interpretation), it is possible to uphold the standard of honesty. Concurrently, the student is maintaining the patient's right to receive the news in its entirety in a compassionate and meaningful manner. The student can assume the responsibility for following up with the attending and advocating for a timely discussion between attending, patient, and student, in which the relevant information is disclosed to the patient.
As students and physicians, we must bear in mind our primary responsibility to our patients, specifically that decisions should be based on what serves the patient's best interests. When a patient addresses a question to a student, it is the student's responsibility to consider his or her ability to provide complete information to the patient regarding the patient's disease, treatment, and prognosis. A student should not provide incomplete or dubious information that could lead to confusion or misunderstanding or compromise the patient's care. Instead, the student—Neil—should address the issue with a senior member of the team. After Alan has been properly informed by his physician, Neil can follow up, answering Alan's questions consistent with his (Neil's) own knowledge and benefiting from the opportunity to learn from the exchange between the senior physician and the patient.
Mary Oliver completed her undergraduate education as a psychology major and studio art minor at the University of Arizona in Tucson, Arizona. She is currently a fourth-year medical student at New York University School of Medicine and plans to pursue a career in obstetrics and gynecology.
Role of the student in discussion of diagnosis and treatment with patients by Mary Ann Hopkins, MD
Medical students often develop special bonds and close relationships with the patients they follow. This can benefit both the educational experience of the students and the care of the patients. In fact, one of the most exciting and important aspects of the clinical years is the development of the communication skills that will make students more effective physicians [1,2].
That said, there is no role for the student in discussing new findings or results with their patients. This discussion is one that the patient and his or her physician should have together at the appropriate time and in the appropriate place. The student may have a role to play after this initial discussion has occurred, but under no circumstance should he or she try to intervene prior to that for several reasons.
Neil and Alan seem to have developed a strong relationship. As a medical student, Neil cannot understand all the ramifications of the CT findings and how they might influence treatment plans and prognosis. Is the CT scan 100 percent diagnostic for metastatic cancer, or could it represent a benign disease process? What is the differential diagnosis of these multiple soft tissue nodules? If this is metastatic cancer, what are the treatment options and what is the prognosis? There are many nuances that need to be reviewed, some specific to the disease itself and some specific to the patient. Although it may seem helpful initially to alleviate the patient's anxiety, discussing test results could potentially have damaging repercussions.
Secondly, the hallway is clearly an inappropriate spot to have any conversation about treatment options. The temptation, if a test is negative, is to let the patient know as soon as you see him or her, either by saying "great news on your test" or giving a thumbs-up sign. However, doing this will only bring attention to the reverse situation; that is to say, not giving a sign will imply that the news is bad. It is always a good policy to give news in person and in a safe and comfortable place. Giving news over the telephone, in the hospital lobby, or cafeteria is a bad policy—you won't be able to give proper comfort to a patient in these circumstances if it is needed.
Yet Neil does not want to lie to Alan nor should he. The best way for a student to address this problem is to be honest and state that, as a student, it is not his or her role to discuss any findings with the patient, since he is not the patient's doctor. Neil can say that he will try to find the attending physician and see if he or she has the test results. If it is at all possible, Neil should try to avoid acknowledging that the results are in the computer; the attending physician may be tied up until later that day and unable to get to the patient. This information could cause unnecessary and perhaps unbearable waiting for the patient.
The relationships that students develop with their patients are unique and privileged. A student is often able to sit and talk with a patient for long periods of time, so that he or she can understand the story and chronology of that patient's disease. The patient may look on the student as a friend and ally in an often frightening time and place . The student may also communicate some of the patient's questions and anxieties to the attending physician. The student can and should explain some complicated principles about anatomy or basic medical principles (although, again, a student should not discuss treatment options and prognosis with a patient). The third and fourth years of medical school provide medical students with rich and wonderful experiences. Through this process, they learn valuable communication skills that will make them well-rounded physicians.
In summary, medical students should never discuss findings or results with a patient. This must be left to the patient's doctor. This is not to say that the student should never discuss medical issues with a patient; there are appropriate issues to explain to the patient, and a good and healthy relationship should develop between them. In fact, feeling the anxiety that the patient is experiencing will help the student understand patients' feelings better when he or she becomes a doctor.
Mary Ann Hopkins, MD, is an attending surgeon at New York University Medical Center. She is also the director of the surgery clerkship. Her major educational interests include the use of multimedia to educate future physicians, how students acquire the ability to reason through a problem, and how to teach students to become compassionate caring physicians. She has also worked with Doctors Without Borders.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
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