Shining a light on shadowing.

SHADOWING PHYSICIANS HAS BECOME AN ACCEPTED WAY for college students to learn what it is like to be a physician. Students follow practicing physicians in their daily activities that almost always include patient care; indeed patient interactions seem to be the high point of the experience. But there are ethical concerns about physician shadowing by college students. Shadowing is not a new idea in medical education. Historically, learning through observation has been a central component of training physicians and remains an important mechanism for medical students to learn history taking and physical examination skills, as well as to become familiar with various aspects of a physician’s life. Currently, firstand second-year medical students are routinely assigned to shadow physicians. Medical students are also introduced to various specialties through shadowing experiences. However, shadowing of physicians by college students is a relatively new practice, and it is difficult to measure the frequency with which it occurs. Students do not necessarily list physician shadowing per se as an extracurricular activity on their medical school applications, but may describe the experience in other terms, such as volunteering, acting as a medical assistant, or working in a physician’s office. One survey of 317 students who requested to be on the premedical advisor’s e-mail list at a small liberal arts college revealed that of the 101 respondents, 80.2% reported some experience with physician shadowing. According to one premedical society Web site, “Hospital shadowing is a must for aspiring MDs—not just because med school admissions committees won’t take an applicant seriously if he or she has never been inside a hospital before, but because hospital experience will help you decide whether you even want to be a doctor, and provide you much-needed exposure to hospital life, physicians, and patients.” Some undergraduate premedical programs actively sponsor physician shadowing programs so students can “see what it means to be a practicing physician.” Participation in at least 1 shadowing experience is often recommended. Other schools use their career networks to enable students “to experience some period of time in the shoes of health care professionals.” Shadowing is also touted as a way to enhance medical school applications because it shows that students have “taken the time to investigate your career choice and to learn about professionals in your career field.” Yet physicians have multiple ethical obligations to their patients that might be violated by allowing college students to shadow their work. First, the relationship between a professional and a client is considered fiduciary, meaning that it is based on trust, and shadowing may be a breach of the physician’s fiduciary obligation to the patient. Physicians, as fiduciaries, must always act in their patients’ best interests, and subordinate their own selfinterests and the interests of others. How is a patient’s welfare served by having a college student present during an appointment with his or her physician? If physician shadowing by a college student may not be in a patient’s best interest, why is shadowing by medical students acceptable? Shadowing by medical students may ultimately benefit society by providing a valuable educational experience that produces more humane, competent physicians. In addition, college students differ from medical students in several fundamental ways: medical students have committed themselves to the study and practice of medicine, whereas college students have not; medical students have been evaluated and admitted into training for the medical profession, whereas college students have not; the primary purpose of shadowing by medical students is to learn medicine, whereas the purposes of shadowing by college students are to help them choose a career and gain admission to medical school; and medical students, from day 1 of medical school, are expected to behave in a professional manner. Many medical schools hold rituals to acknowledge admission into the profession for entering students; some involve the recitation of oaths of professionalism. In addition to their fiduciary obligations, physicians have other duties to their patients that are breached by college student shadowing, including maintaining privacy,