As the house officers have become more numerous and more skilled, the position of the medical student has changed. House officers are licensed to practice medicine; students cannot practice by law. A student cannot write orders, even for something as simple as raising a patient's bed, without having them countersigned by a house officer.
Legally, a student is permitted to employ nothing other than diagnostic instruments, and then only for the purpose of diagnosis. In practice, this ruling is stretched to mean that a student can, under supervision, perform a lumbar puncture, a thoracic or abdominal tap, or a bone-marrow aspirate; he can suture wounds in the emergency ward; he can also mix medicines, start intravenous infusions, inject medicines intravenously, and give a blood transfusion. Additionally, he is expected to have competence in a variety of laboratory procedures and tests.
The medical student's officially sanctioned functions thus lie somewhere between those of a doctor, a nurse, and a laboratory technician. It is not surprising that no one knows what to call him. Instructors with a group of second- or third-year students will often introduce them to patients as "doctors in training" or "these young doctors." Fourth-year students, seeing patients alone, will introduce themselves as "doctor." Until a few years ago, the students even wore name tags which said
"Dr.," but this practice was abandoned
after the hospital was advised it constituted misrepresentation that might have legal consequences. Student name tags now give only their names; those of interns and residents say "Dr."
It is not clear why medical students are called doctors in front of patients, especially since so few patients are fooled by the appellation. One can view the whole business as a harmless convention,
in which the hospital pretends that its students are doctors, and the patients pretend to be taken in.
Why bother? Instructors say that this small white lie comforts the patients, who would be upset to learn they were being examined by students. Something of the same sort happens with interns, who occasionally pass themselves off as residents in the belief that this soothes patients. It is true that the folklore-and the mass-media image-of the medical student and the intern is distinctly unfavorable, and these negative connotations persist until residency. (Dr. Kildare, that charming, all-knowing physician, was a resident who spent much prime time dealing with neurotic, guilt-ridden, fumbling interns and students.) "Even now," according to George Orwell, "doctors can be found whose motives are questionable. Anyone who has had much illness, or who has listened to medical students talking, will know what I mean." In a single, paradoxical stroke, he dismisses the motivations of some doctors, but all medical students.
The position of the medical student is thus peculiar, and occasionally comical. In society at large, he finds himself eminently marriageable and a good credit risk, thus enjoying the approval of those two bastions of conservative appraisal- matrons and bankers. In the hospital, however, those same matrons and bankers want nothing to do with students, and nearly every student has had the experience of examining a woman who grumbles and complains throughout the history and physical and then politely asks if the student is married.
In the end, one suspects that the practice of labeling students as doctors is misguided. Patients ought to be told explicitly who the students are; a moment's reflection shows many advantages to such a practice.
For one thing, most patients coming into a teaching hospital are already apprehensive about being used as guinea pigs. They have heard vague reports that "You'll be in the hands of students and interns," and this is not really true. Patients entering the hospital-already sick and afraid-are almost always unfamiliar with the hierarchy of decision-making that provides careful checks on junior men. Against this background of apprehension is added the fact that everyone introduces himself as a doctor, while the patient knows perfectly well that some of those doctors are students. Thus, failure to identify students increases anxiety instead of relieving it.
Further, it is a common observation on the wards that students are popular with patients. Students have more time to talk to patients; hospital life for a patient is boring; patients like the attention. (Frequently they will rank the house staff according to warmth and attentiveness. A friendly student who has had the experience of working with a brusque resident knows how often patients
conclude that the resident is a student, and vice versa.[This implies that patients associate brusqueness with professional ineptitude, and that may be valid])
Finally, it is explicit in the bargain any teaching hospital makes that a patient will receive better care, but in return must put up with teaching. The teaching function might as well be identified as such. In any case, as Frederick Cheever Shattuck said many years ago, "Before swerving from or denying the truth we should ask ourselves the searching question, 'For whose advantage is this denial?' If it is in any measure for our advantage, or seeming advantage, let us shame the devil."
How do students, house officers, and senior men combine to produce the ward teaching system? As exemplified by Mrs. Murphy's experience, the system works as follows.
When the ward is notified that a new patient is being admitted, the student goes down to the EW and examines the patient. On occasion, he has to hurry to beat the house officer, but students learn to do this, and the best house officers will go to great lengths to allow the student to perform the initial examination. The reason for this is that with each succeeding history and physical, the patient becomes more accustomed to the routine of delivering his story in an orderly but unnatural manner. Fresh patients are the most difficult to get a history from, and therefore the most prized.
After a student has examined the patient, the resident conducts a second examination, and then comes out to talk to the student about the case. The resident generally has only three questions: "What did you find?" "What do you think he has?" "What do you want to do for him?" Interestingly, these are the only really important questions in all clinical medicine.
A discussion of diagnosis and treatment follows; if the resident agrees with the student, he will let him write the orders, then countersign them. Diagnostic procedures such as lumbar puncture, bone-marrow biopsy, and so on are usually done by the student under the resident's supervision. By tradition, patients are expected to be "worked up" as much as possible on the day (or night) of admission. This means that in addition to the history and physical, the ward team is supposed to look at the blood morphology, do a white-cell count, a hema-tocrit, an electrocardiogram, urinalysis, review the chest X ray-and whatever other, more sophisticated, tests are necessary, all at the time of admission.
The student may do much or all of this, but he really has no control over the patient's care. Most of the decisions-decisions at the time of admission, and all later decisions-are made by the admitting house officer. This is why the medical service regards "admitting a patient" as directly equivalent to the surgeon's "doing a case." In each instance, only one person can have the responsibility of decisions on patient care. And while it is valuable to look on, it is not the same thing as doing it yourself. The experience of responsibility is not transferable.
Each house officer thus has a series of "his patients" on the ward; these are the patients he originally admitted, and he feels primary responsibility for them throughout their hospital stay. He is expected to know more about his patients than anyone else, though others must know enough to handle details of care when the resident is off duty. The sense of individual responsibility is so strong that it is couched in possessive terms. One house officer may ask another, "Is Mr. Jones your patient?" and be told, "No, he's Bob's."