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?"
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.
American Medical Association. Principle IV. Principle of Medical Ethics. In: Code of Medical Ethics, Current Opinions, 2002-2003 edition. Chicago: AMA Press; 2002:xii.
Medical Professionalism Project. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002:136(3); 243-246.