Personal Views: Calling a spade a spade
Authors: Daniel K Sokol
Journal: BMJ (2005)

Medical ethicists are notorious for their interest in rare and far fetched cases. “Vive la difference!” could be an ethicist's motto. Here I go against the trend and dwell on one of the most ordinary ethical issues in clinical medicine. So ordinary is it that many do not consider it an ethical issue at all. What is undeniable is that the issue—ethical or not—affects scores of patients, doctors, and medical students across the country. Should medical students be introduced to patients as “student doctors”?

Most medical students, at some time in their training, have been called “student doctors” or “doctors” by their seniors. Registrars and consultants regularly boost the egos of their eager students with a taster of that delectable title, Doctor. Many patients are led to believe that student doctors are bona fide doctors and go on to address them as such for the rest of the consultation. More than encouraging the students, the title also serves to reassure the patient that the nervous looking youth before them is not feebly attempting to assault them but is examining them. The title acts as a verbal tranquiliser, putting anxious patients and students at ease and “getting the best” out of both parties.


Many patients are led to believe that student doctors are bona fide doctors


Throughout their stay in hospital, however brief, patients are asked dozens of questions by healthcare staff. It can be an exasperating experience (BMJ 2004;328: 471). A weary or irate patient is more likely to answer questions if asked by a doctor. Introducing students as student doctors increases compliance and provides opportunities for the students to practise their history taking. So what's the fuss, if no one is harmed by the benevolent subterfuge? Is this another case of an ethicist creating an ethical issue out of nothing?

Arguably, patients have a duty to allow medical students to train on them. This is the price to pay for technically competent doctors. To use Kant's distinction, the volunteering is not a “perfect” duty (it doesn't have to be discharged at every opportunity) but an “imperfect” one (it must be discharged only some of the time). In other words, although as patients we have an obligation to help occasionally, we have some leeway as to when to be guinea pigs. If medical students masquerade as doctors it becomes difficult for patients to fulfil their imperfect duty. As a duped patient I may be more dutiful than I need to be. My right to refuse to assist on this occasion is taken from me. My autonomy is subverted by the false belief that I have no choice.

Deceiving people is generally a bad thing. It tends to diminish trust (if discovered) and violates the deceived person's autonomy by imposing or maintaining a false picture of the world. Introducing students as student doctors is not factually false. It may not even be an act of deception if the senior doctor does not intend to mislead the patient. Yet it may well be unintentionally deceptive. Many patients are convinced that the student is a doctor and behave accordingly, perhaps disclosing sensitive information that they would not otherwise disclose. Patients have duties to doctors that they do not have to medical students. Clear identification allows patients to exercise the appropriate duties to the relevant people.

Deception in medicine is not always wrong. There are exceptional circumstances where benign deception is preferable to an adverse truth or where ambiguous words can defuse or prevent a crisis. Yet the prima facie wrongness of deception is a good reason to avoid encouraging this practice among medical students, lest they get into bad habits. Consultants who encourage deception so early in the medical careers of students set an undesirable precedent and make dubious role models. Honesty is intimately linked to trust in the doctor-patient relationship. If I discovered that the four youthful doctors who just performed scrotal examinations on me were, in fact, verbally disguised medical students, I would be rather annoyed. My general trust in the medical profession would be diminished. While some deceptions are unavoidable, this obfuscation is unnecessary. As most patients are prepared to assist students if asked directly, verbal trickery is simply not needed.

If medical students would not be introduced as student doctors to medically qualified patients, neither should they be to any other patients. Patients should be treated with equal respect, whatever their medical knowledge. Boosting the egos of medical students, providing them with practical experience, reducing the anxiety of patients—these laudable aims can be achieved in ways that do not subvert autonomy or betray patients' trust.