AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2012, Volume 14, Number 9: 701-704.

ethics case

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The Student Becomes the Patient

When a medical student needs to be hospitalized, the paramount concern of the student affairs dean is promoting the student's health, followed by protecting her privacy and supporting her medical education.

Georgette A. Dent, MD

Kathryn is a medical student who struggled with an eating disorder throughout high school. She was hospitalized for 6 weeks during her sophomore year and then worked with a therapist on an outpatient basis for 2 years. By the time she reached college, she was at a stable, healthy weight and had developed coping strategies for her underlying control and anxiety issues. She excelled as an undergraduate and was accepted into her first-choice medical school. She did very well during her first 2 years, breezing through most of the preclinical curriculum while maintaining healthy eating and exercise habits.

Now in her third year, Kathryn has found that the stress of clinical rotations is taking its toll. She has fallen back into old habits of restrictive eating and overexercising. When she visited her parents during winter break, they were shocked by her significant weight loss and obvious distress and confronted her with their concerns. Kathryn admitted she was terrified at the prospect of gaining the 30 pounds necessary to reach a normal weight. Eventually, she agreed that she needed help and expressed a desire “to be done with this whole eating disorder once and for all.”

Kathryn was waiting in front of the student affairs dean’s office on the first Monday morning after winter break. The dean was startled by Kathryn’s baggy clothing, sunken cheeks, and dark circles. Kathryn looked nervous but spoke matter-of-factly. “I need to talk to you,” she began. “My parents and I have decided that I need inpatient care, and I don’t know what that means for my rotations.” She looked at the ground. “And can we please keep this as confidential as possible? I don’t want people finding out.”

Commentary

Medical school can be an intense and stressful experience, and medical students are vulnerable to psychiatric disorders. The paramount concern of the student affairs dean in this example is promoting the student’s health, followed by protecting her privacy and supporting her medical education.

Student affairs deans play multiple roles in medical schools, representing students, the institution, and the medical profession. As the student’s advocate and often counselor and confidant, the dean should support the student in getting access to mental health care in a manner that protects her privacy. As an institutional representative, the dean should make sure that laws, such as the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA), are followed and that the school complies with accreditation standards set by the Liaison Committee on Medical Education (LCME). As a representative of the profession, the student affairs dean should make sure that there is appropriate documentation of the student’s record in the medical student performance evaluation (MSPE) that will become part of her residency application.

The Student’s Health

Medical schools should have protocols in place to ensure that their students get mental health care in a timely and confidential fashion. LCME Standard MS-27 stipulates that “a medical education program must provide medical students with access to diagnostic, preventive, and therapeutic health services.” The standard’s annotation specifies that “a medical education program should have policies and/or practices that permit students to be excused from class or clinical activities to seek needed care” [1]. The best option would be for Kathryn to be hospitalized at an institution not affiliated with her medical school. The medical school should have a policy or practice to ensure this. To address Kathryn’s concern about her rotations, the dean should explain that she will be allowed to take a leave of absence and return to the curriculum when her health is better. The leave of absence is discussed in more detail below.

The Student’s Privacy

If Kathryn is hospitalized at an outside institution, her privacy is preserved because only the student affairs dean is aware of her situation. While obtaining care at an outside institution is preferable, sometimes this is not feasible because of the acuteness of the student’s condition or because the treatment needed is only available at the student’s home institution. If it is not feasible to refer Kathryn to an institution unaffiliated with her medical school and she is hospitalized at her home institution, then the student affairs dean must take careful steps to ensure that Health Insurance Portability and Accountability Act and Family Educational Rights and Privacy Act requirements are followed. During treatment, Kathryn should not be exposed to her student peers. Additional privacy concerns related to the student’s return to the curriculum are mentioned below.

The Student’s Education

Leave of absence. One of the admirable aspects of this case is the fact that the student came forward of her own accord. Physicians and medical students must have the insight to remove themselves from the care of patients, or in the case of students, from their coursework, if they have a condition that prevents them from performing competently. At the University of North Carolina School of Medicine, students sign a technical standards agreement prior to matriculation that stresses the importance of mental fitness, acknowledging that, while students with psychiatric conditions may be successful, “it is essential that a medical student be willing to acknowledge the disability and accept professional help before the condition poses danger to self, patients, or colleagues” [2].

When students proactively identify their needs before their condition has had a negative impact on their performance, in many medical schools they will have the option of choosing to take a personal leave of absence. On the other hand, if the student’s condition has resulted in poor academic performance or a lapse in professionalism, then the student would most likely be remanded to the school’s student promotions or progress committee and either placed on a medical leave of absence or dismissed.

Return to the curriculum. The conditions under which Kathryn may return to the curriculum will be determined by her leave status. If allowed to take a personal leave of absence, her requirements for returning might be minimal. On the other hand, if she had been placed on a medical leave of absence, in many medical schools she would have to be examined by a mental health professional in contact with her primary psychiatrist, psychologist, or therapist to determine if and when she was healthy enough to return and outline any necessary follow-up treatment. When Kathryn returns to the curriculum, the student affairs dean would work with the clerkship directors to see that she is allowed to keep necessary treatment appointments without penalty while still meeting course and clerkship objectives.

If Kathryn had been hospitalized at an institution affiliated with her medical school and had not yet completed her psychiatry clerkship, then ideally she should be assigned for that clerkship to another institution. If she must complete her psychiatric clerkship at the same hospital at which she was a patient, at a minimum she must not be assigned to the eating disorders unit.

In accordance with LCME standard MS-27-A, “the health professionals at a medical education program who provide psychiatric/psychological counseling or other sensitive health services to a medical student must have no involvement in the academic assessment or promotion of the medical student receiving those services” [1]. Faculty members or residents involved in her care must not later be in a position to evaluate her. The Department of Psychiatry at UNC has a policy that states that residents cannot grade or evaluate students who have been their patients. In the event that the student must complete her psychiatry clerkship at her home institution, the student affairs dean would work to make sure the Department of Psychiatry policy was followed.

Residency applications. Another important consideration in this case is how Kathryn’s illness and treatment should be handled in her medical student performance evaluation (MSPE or dean’s letter), which depends on whether or not her mental health had an impact on her performance. If there was no impact on her performance, the MSPE would say that she chose to take a personal leave of absence. Depending on the student’s specialty choice, she might be advised to address the leave of absence in her personal statement, perhaps pointing out that coping with her illness has given her additional insight into the experience of being a patient and should make her a better physician. She could also reassure residency program directors that the insight she gained from her treatment improved her ability to self-monitor her condition so that it will not compromise her ability to fulfill her responsibilities as an intern and resident. Our students have had good results in the National Residency Matching Program by being candid in their personal statements about the challenges they have faced as medical students.

On the other hand, if the student had academic or professionalism problems that resulted in action by the student promotions or progress committee, then the MSPE would state that she was placed on a medical leave of absence to address the problems leading to those troubles. In this situation, it would be essential for the student to use her personal statement to give context to her situation.

Conclusion

In this scenario, the student approaches the student affairs dean with a very immediate need. The top priorities in such a situation are to identify the most appropriate treatment option for the student, to reassure her that she is doing the right thing by seeking treatment and that her confidentiality will be protected, and to address her questions about the impact treatment would have on her clerkships. Medical students should be able to access mental health care and maintain their privacy. Medical schools should treat students with psychiatric illnesses in a way that models how they would like to see students treat their future patients. Treating medical students who have psychiatric illnesses with compassion and sensitivity is the right and ethical thing to do, if medical schools seek to produce compassionate and sensitive physicians.



References

  1. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs; May 2011. http://www.lcme.org/functions.pdf. Accessed June 27, 2012.
  2. University of North Carolina School of Medicine. Article 5: Responsibilities of medical students. http://www.med.unc.edu/md/governance/policies/files/ Article5ResponsibilitiesofMedicalStudents2012220.pdf. Accessed August 9, 2012.

Georgette A. Dent, MD, is the associate dean for student affairs and an associate professor of pathology and laboratory medicine at the University of North Carolina School of Medicine in Chapel Hill. She is a member of the Liaison Committee on Medical Education and is a former chair of the Association of American Medical Colleges Group on Student Affairs.

Acknowledgment

My thanks to Alice Pelland, MEM, at the University of North Carolina School of Medicine for her thoughtful comments and review of this manuscript.

Genetic Profiling of Medical Students, August 2012

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.