Why medical students are 'medical students'.

Who are you? What is your role in the medical setting? What is your professional status? Who am I? This last question may be answered easily by looking to the end of this editorial, but when we meet face-to-face, knowing the answers to questions such as these usually requires some other source of information. Alas, too often even today, some patients (and one fears some health professionals as well) answer these questions with reference simply to cues such as class, race, and gender, leading to unfortunate mischaracterizations—not all women in the hospital corridor are nurses or social workers, for example. A name tag can indicate an unknown person's professional identify and status. A name tag (often with a picture ID) also serves a security function by indicating that the person belongs in the setting. A name tag used for this purpose primarily answers the question “Does this person really work here?” As both status and security markers, name tags are worn in a variety of settings, from zoos to factories to airports. But perhaps nowhere are they so important as in health care, where people—our patients—are at their most vulnerable: ill, afraid, in pain, partially clothed (or not at all), often separated from their friends and family, and implicitly obligated to follow the instructions of the professional staff. Who is the person coming in the door? That question is often answered by their name tag. What, precisely, do name tags tell us about the person? Well, for one, the person's name. But let us hope that we are past the days when a patient might refuse to be cared for by someone only because his name is “O’Connor” and not “Gottlieb,” or vice versa. Obviously, name tags in the medical setting are intended to convey more than names. They also serve as role markers, although in fluid settings such as the hospital ward any of a wide range of professionals might assume the role of “blood drawer.” More than merely marking a role, the name tags also indicate where a person exists in the professional hierarchy of medical workers. That standing may then be read as a marker of that person's professional status. The article by Silver-Isenstadt and Ubel in this issue examines precisely how U.S. medical school and hospital administrators label medical students. The basic idea behind this article was brilliant in its simplicity, proving (once again) that insightful research can be done without an army of research assistants or a 4.2-gigabyte hard drive. The authors wrote to all medical student campuses in the United States asking for photocopies of the name tags worn by medical students and received a response from 78%. Their findings are simple and striking—almost half of the respondents used some formulation other than “medical student” to describe the status of their students. (Full disclosure caveat: My university prints “Medical School” on the name tag, a choice not discussed in the article. I do not know if we responded to the survey.) Terms used around the country other than “medical student” include “student physician,”“student doctor,”“MD student,” and, my personal favorite, the letters “MD” in large type followed, in much smaller type, by “Prog.” (The authors do not state the meaning of this abbreviation—I assume it means “Program.”) Not content with simply documenting the variation in labels, the authors then went on to find out what these terms mean to the most important set of readers: patients. They selected outpatients expected to wait at least 30 minutes for their appointments. (I was appalled but not surprised to hear that it was seemingly easy to identify such patients.) The authors asked the patients to rank order the various descriptors from the least medically experienced to the most medically experienced. Perhaps not surprisingly, these patients assumed that people labeled as “medical students” have less experience than people labeled with other descriptors such as “student doctor,”“student physician,” and “MD student.” Methodologic quibblers might question the convenience sampling technique used by the authors, but I doubt even quibblers believe one would find a different response from a larger and more systematically obtained sample. Faced with the results of this study, we can no longer pretend that all the various terms used on name tags mean the same thing to patients. Identifying medical students with any term other than “medical student” is, as the authors suggest, obfuscation. By the standards of contemporary America, to obfuscate intentionally or to dissemble outright (a nice word for “lie,” which is probably more appropriate) in ways that imply (or state) that medical students are physicians is blatantly unethical. Program leaders doubtless claim to hold honesty as a (nearly) absolute rule. If they intend to deceive vulnerable patients who enter the walls of the medical center seeking care, one must wonder why. I suspect that the rationale is based on the belief that overstating medical students’ status will more likely get patients to accept care from medical students. The study shows clearly that such deception works, that the use of obfuscatory descriptions does, in fact, change how patients perceive the medical qualifications of their caregivers. Is such an approach necessary? It is not at all clear that most patients will refuse to be seen by medical students. Many patients understand the societal need to train physicians. Many others will be appropriately reassured when the student's well-supervised role in the system is explained. Patients admitted to teaching hospitals may understand that team members are at various stages of the educational process, carrying out their tasks under the supervision of those with more experience and status. They may perceive a team of caregivers, believe that it is headed by a person of superior ability, treat the internal structure and machinations of that team as irrelevant, and trust either those people or, more likely, the institution, to ensure that the team is competent and behaves in the patient's best interest. If so, there would be little reason to hide the fact that there are medical students on the team. Indeed, patients may be as happy (or more happy) to receive the calm, unhurried ministrations of a fourth-year medical student as they would be to be attended to by a harried, cross-covering intern. The question of how patients feel about being seen by medical students lies beyond the scope of the article in this issue, but it is a question worthy of empirical research. I also question the “hide the medical student” approach from a matter of public policy. It is better for people who pay for much of medical education to see and to understand precisely where and when it is going on. Assuming, for the sake of argument, that the medical education system will run more easily from the educator's perspective if patients do not fully understand that they are being seen by medical students, is obfuscation what we want? Should we accept and support a system that continues to perpetuate historical inequalities reminiscent of the older days of medical education, in which patients—poor, often people of color—accepted being “guinea pigs” to obtain free health care? Do we want to teach our students that their best interests are served by hiding their identity? I hope not. There are reasons for specific concern about the few medical student name tags that included the letters “MD” in the text. Many of our patients would find it difficult to read a name tag. Some are illiterate, others have impaired vision, and a considerable proportion of patients seen in teaching institutions fall into one (or both) of these two groups. It is likely that such patients will recognize the initials “MD,” yet be unable to read the accompanying text. Patients reading this name tag could reasonably assume that they were being seen by an MD, even when they were not. If we want patients to trust us, we must be honest with them. If we are not, patients are likely to distrust the educational system in all its aspects. How do faculty describe the people they teach? Do we say, “I’m off to give a lecture to student physicians”? How do these students describe themselves? Do they say, “I’m a student doctor”? Or “I’m an MD student”? I think not. No, we teach “medical students,” they refer to themselves as “medical students,” and that is how they ought to be identified to patients. All U.S. medical students ought to have name tags that read “Medical Student.” According to this study, slightly over half of U.S. campuses already do. The rest ought to do the right thing as well.