Case and Commentary
Apr 2007
Case
Leah is a third-year medical student doing her internal medicine rotation. She is a diligent student who has quickly learned her role and responsibilities. She enjoys taking care of patients and does her best to know all of their current medical needs and treatment plans. She is also aware that achieving a high grade in this clerkship is important, since she plans to pursue a career in internal medicine.
Every morning Leah dutifully pre-rounds on her patients so that later, on team rounds, she is able to share the patients' overnight events, vital signs for the past 24 hours and results of that morning's lab work with the other medical students, interns, residents and the attending physician. Leah has done such exemplary work that the interns covering her patients save rounding on her patients for last in the morning and occasionally, if they are particularly frantic, do not see them at all before the work day starts.
One day the full team was rounding with the attending physician, who joined the team one morning each week. He had a somewhat gruff demeanor and liked everything to be presented in a specific manner, with no straying from the typical format. In fact, he tended to be so rigid that medical students often did not present their own patients to him, lest he be annoyed at the student and the team. He was also responsible for 50 percent of the student's grade. Leah was presenting that day, as was required at least once during her clerkship. Her patient was Mrs. Lang, a 72-year-old woman with coronary artery disease, systolic heart failure secondary to ischemic cardiomyopathy, type 2 diabetes mellitus and chronic renal insufficiency who had been admitted for cellulitis.
Leah gave a seamless presentation and had started to summarize the most recent labs when she realized that she had logged off the computer without writing down the basic metabolic panel (BMP) for Mrs. Lang in order to be on time to rounds. After a moment of hesitation she said that the BMP was unchanged from previous readings for this patient—whose baseline renal insufficiency had been constant throughout her visit. The intern and resident both jotted down on their route sheets that the BMP was unchanged, planning to check the values themselves when they had the time.
Two hours later, after their lengthy rounds, Leah finally had a chance to sit down at a computer and check Mrs. Lang's labs. Just as she saw that Mrs. Lang's potassium, BUN and creatinine were elevated, Mrs. Lang's intern was paged by the pharmacist, who was inquiring about the appropriate antibiotic dosing, given that the new lab results indicated acute renal failure.
Commentary
Clinical clerkships serve many roles and open up several opportunities for medical students. These rotations are an introduction to clinical medicine and allow students to apply the textbook science they have studied diligently to diagnosing and treating patients. Moreover, they are part of a student's schooling. And it is this role that is important to remember when thinking about this case. Leah is a student, not a physician, and, therefore, her primary job is to learn. Medical school is the time when students must develop their medical fund of knowledge as well as the principles of professionalism that they will practice for the remainder of their careers. In this case, Leah compromises her integrity to offset appearing unprepared and risking a bad grade for the clerkship, an action that ultimately endangers her patient's health. This act should be examined more thoroughly because it highlights several important points regarding medical students' responsibilities to themselves, their peers and their patients.
Whether one is in elementary school, high school, college or medical school, evaluation is a part of being a student. Evaluations serve as markers for a student's success and competency in the field. Leah's behavior during these rounds is reflective of her motivation for success. An important component of a medical student's assessment is professionalism, which encompasses both being prepared for a presentation and being truthful.
When these two demands conflict, which one should prevail? The answer seems obvious, but this is not always the case. Leah is conflicted by these demands of professional conduct because she is worried that her grade for the clerkship is at stake. She demonstrates professional behavior by conscientiously arriving on time for rounds. Making assumptions about concrete medical data, however, when a person's health or life is at risk is unprofessional, unethical and unacceptable. The moral approach is to be honest and simply summarize the most recent lab data of which she is certain and apologize for not knowing that morning's results. The attending physician and the other team members may be surprised that she didn't know the information, given her usual diligence, but her professionalism and clerkship grade will probably not be jeopardized completely.
Leah clearly fears taking the more honest approach, thinking it will damage not only her evaluation but also the excellent impression the team has of her. Being unprepared once should not negate the exemplary work she has done up to this point. Instead, her fellow team members and the attending should recognize truthfulness in this situation as a positive attribute. Besides, there is still time remaining in the clerkship to make up for this lapse. Moreover, Leah should not just worry about her grades but also about her ability to practice medicine independently as a future physician. As members of the medical community, physicians are expected to develop a process of self-regulation. Students need to learn that as clinicians they must sometimes compromise their self-assurance to benefit their patients' health, and being comfortable with this is a process that should begin and grow during medical school for all students. Leah should use this experience as an opportunity to regulate her own actions and to develop a sense of comfort with forfeiting her pride for a patient's well-being. She has not yet realized that this is an important skill to hone prior to gaining sole clinical responsibility for a patient. But as a result of her actions, she willmost likely learn this lesson.
The clinical student's primary role
As mentioned earlier, learning during a clinical clerkship is paramount to a student's future as a physician. This is why the only responsibilities for which students can truly be held accountable are those that contribute to their education. The case mentions that Leah "has quickly learned her role and responsibilities." But should a medical student's role or responsibility on a team go beyond learning? Students have many educational obligations, in addition to their role as part of the clinical team. As students, they are required to attend lectures, prepare write-ups, read about their patients' diagnoses, practice writing notes and study for written examinations. As members of the medical team, they are often relied on to help gather data, e.g., lab results, radiology reports, and to call other clinicians for input into a patient's case. But this job is merely to aid house staff and lessen their burden, because it is ultimately the house staff who are accountable for collecting and knowing this information. It is then the house staff's duty to teach the students what these data mean for the patient. Thus it should only be considered a medical student's responsibility to gather data when the residents and interns are fulfilling their role as educators. In this way, while the medical student's work is contributing to patient care, it also becomes a learning experience, allowing the students to fulfill their obligation to learn.
Because of the team's reliance on students to help gather important clinical information, the expectations of medical students grow to a point that can sometimes be unfair. It is because of these expectations that most medical students begin to feel pressured to stay on top of their patients' medical data and information related to their ongoing work-up. This pressure most likely contributed to Leah's hesitation on morning rounds. Her moment of uncertainty occurred because she knew that the correct thing to do was to tell the truth, but, to her, not meeting the team's expectations was worse than not being honest. This leads back to the principles discussed above. Students must realize that, despite their overwhelming desire to impress and succeed, being candid is always the best option—regardless of the immediate consequences. In the long run, this will help them develop the ethical behavior they need throughout their careers.
