Teaching Hospitals - Do They TRY to Trick You?

Hi, Raili ~  I've had most of my treatment @ UCLA, and I would say 95% of the time, if a resident, med student or visiting doctor is present -- which they have been quite a bit --  he/she will be introduced by my doctor as such, and my doctor will ask if it is okay if they watch, assist, or whatever they're there to do.  I have never felt that it was an imposition, but more that I was grateful to be treated by such fabulous docs and who are held in such high esteem by doctors from around the world.

I had only one experience that sounds a bit like what you're describing, and in retrospect, I was not entirely happy with the way it unfolded.  It was an MRI-guided biopsy that had some equipment glitches (so it took awhile) and resulted in profuse bleeding and nausea.  Of course, at the time, I didn't realize I was probably in the hands of residents, nor did I realize how difficult a procedure it would be.  But, in retrospect, I think what you're describing was the reason it was not a particularly good experience, so I feel sorry for you if you've endured that on a regular basis.  It does make you feel a bit duped to be treated by students or residents without realizing it.    Deanna   

Raili, I've heard that teaching hospitals are the best place to go for treatment, because they're on the cutting edge (haha) and really keeping up with all advances in the field.

That said, I've had some not-so-great experiences with treatment by residents and other doctors-in-training. I went for a colorectal surgical consult back in August (and I thought THAT was going to be my excitement for the year). Waited forever to see the doctor. Then my husband and I are ushered into a smallish exam room, the doctor comes in with like 3 or 4 other young docs (I think one was an intern - meaning pretty much right out of med school). "Oh, you don't mind if we have the training docs here," the doctor tells me. (Not ASKS.)

Then the youngest doc proceeds to take my history, and she's a little fumbly and frankly I'm terrified because I'm in an area of the hospital that says ONCOLOGY everywhere. One of the young doctors had the nerve to ask, "Do you know why you're here?" As if I had no understanding at all of my medical condition.

When it was all over my husband said the exam was as much about the surgeon teaching young doctors as it was about my health and condition and concerns.

I don't think they think of it as duping you but as a necessary part of training doctors, who after all have to go on to treat patients.

When I saw a breast surgeon a few weeks ago sure enough she shows up with a couple of young docs. (Same hospital.) Actually the man seemed so respectful and nice (and I don't mind having men docs) I felt bad but I asked if they could leave. He did right away and the look on his face was nothing except respectful and kind.

I'm sorry you went through an uncomfortable experience. I really think hospitals and surgeons need to slow down for one or two seconds, introduce people, ASK the patient if it's OK - and say, It's really fine if you want to be with just the doctor. I think a lot of people would say it's no problem when asked... so they shouldn't worry about their training being derailed. But this way it leaves you with such a bad taste, like you've been railroaded into something.

Best wishes for the future! 

Most of my treatments were not at a teaching hospital, so I haven't run into this situation very often. But my rads were at a major NYC hospital (where almost all hospitals do some kind of teaching or training), and the rad onc occasionally had a phalanx of trainees trailing behind her. However, I was asked if I minded their presence for a history and very brief [as in chest only] physical that was done by the rad onc, not one of the trainees. About halfway through my rad treatments, one of the trainees redid my measurements to be sure things hadn't shifted. He was the most "senior" of the group, and it seemed like he was ready to go out on his own, so it wasn't a problem to me.

Now, my PS, whom I consulted for a delayed DIEP recon, has said he often has another surgeon in the operating room with him. I knew that before I consulted him, so it wasn't a surprise. He also introduced me to and asked if I minded the presence of another doctor during the workup and evaluation who might also be in the operating room at the time of my surgery.

I figure, it's a 10 hour operation and he's got to take a break or two during it. His regular co-surgeon is as fully qualified as my PS, and having him take over to let my PS have a quick breather (meal, bathroom, whatever) would only be logical and I'd have no problem with that. But if the observing doctor was handed the reins (and really, how would I know?), I would not be as comfortable. So I plan to read the fine print in the paperwork I'm asked to sign before they take me off to surgery...and my sister, who will be with me at the hospital, knows even more about these things than I do (she is married to a retired PS) and will be my advocate while I'm under anesthesia.

My experience?  All good.  No problems whatsoever.

I've been going to an NCI-designated Comprehensive Cancer Center (part of a major university teaching hospital) for everything, from my initial BC diagnosis 2 years ago, the 6 months of surgery and chemotherapy, and my ongoing follow-up care.

My experience is consistent with what flash described.  I knew from the outset that part of being treated at a university teaching hospital involved interaction with "physicians-in-training."  Usually, those trainees were residents or fellows; occasionally they were 4th-year medical students.  My breast surgeon (a surgical oncologist) almost always has a 4th-year medical student working with her.  The student will come into the exam room first (after the nurse has had me change into a gown).  After stating his/her name, the student always says, "I'm a medical student working with Dr. "X". Do you mind if I examine you?".  He/she will examine me and ask all the usual questions.  Then he/she will leave, and Dr. "X" will come in (sometimes accompanied by the student; sometimes not.)  Note that a medical student should not use the term "doctor" in reference to him/herself, and hospital staff should not refer to a medical student as a "doctor".

I've found medical students to be as respectful and careful as the fully-trained physicians ... sometimes even more so.  I had a whole cadre of doctors and doctors-in-training involved in my mast/SNB and follow-up care in the hospital.  Led by my surgeon's "fellow" the entire group came in to check on me the morning after my surgery.  The fellow removed my bulky bandage and discreetly examined my incision, while the residents answered my questions and asked me some of their own.  One of the medical students noticed that the surgical tape had peeled off a small piece of skin on my upper chest.  He came back on his own a few minutes later, to apply some wound ointment and a non-stick bandage to the sore spot.  I had met him 3 or 4 times in my surgeon's office by then, and I'd gladly have written him a letter of recommendation if someone had requested it.

One thing I want to make clear is that "residents" and "fellows" are doctors.  Residents, whether newly minted "first-year" or experienced "chief" (or "senior"), have graduated from accredited medical schools, passed all levels of the national board exams, and are licensed to practice medicine.  They can legally and ethically introduce themselves as doctors, and examine and treat us.  There is nothing surreptitious about a teaching hospital allowing residents to treat patients.  They are not "sneaking" them in on us when we're vulnerable. 

What a resident lacks is board certification in a medical specialty area.  To obtain board certification, a resident must complete from 3 to 5 years of supervised, in-practice training in a particular field, such as general surgery, internal medicine, or family practice.  A few residencies require medical school graduates to complete a year of general training (formerly called an internship) before they can begin the residency program.  And, some residency programs in highly specialized fields or multidisciplinary areas last as long as 7 years.  It's not unusual to require residents to complete 2 or 3 years of training in the more routine aspects of a field of practice, and then another 2 or more years in the area of specialization.  After that, the resident must pass a "board exam," and possibly meet other requirements, to obtain board certification and work independently.  Here's a website that provides information about residency programs in the U.S.:  http://www.nrmp.org/res_match/about_res/index.html

After successfully completing a residency and becoming board-certified in a particular field of practice, a physician might want to focus even further in a subspecialty by doing a "fellowship".  Thus, "fellows" are a level above the highest-level residents.  Fellowships require from 1 to 3 years of supervised training under the true "experts" in a field of medicine, generally at a nationally-known teaching hospital.

I suppose it's possible to avoid all contact with fellows, residents, and medical students, by insisting that only the "attending physician" will be allowed to examine or treat you.  Personally, I'd rather be examined by a 4th- or 5th-year resident in the Surgery or Oncology service at a teaching hospital, than by some of the general practitioners I've dealt with.  And, I'm not easily intimidated by medical students.  It's much easier for patients to intimidate them.

otter

Sassa, that was a truly horrible experience.  I am so glad you were knowledgeable enough to understand what was happening to your daughter and assertive enough to do something about it.

I did not mean to imply that nothing bad ever happens at a teaching hospital.  The main purpose of my post was to clarify the status of "residents".  The majority of physicians working in a teaching hospital at any given time will be residents.  There simply aren't not enough attending physicians (clinical faculty) on duty to handle all the patient care. 

Personally, I didn't care whether the physician in my room was a 3rd-year resident or a 6th-year resident or a 1st-year fellow.  I needed to trust them, just as I had to trust the nurses who provided the day-to-day care.  Actually, I was more concerned about the training and experience of the nurses.  Most of the time, they did not introduce themselves or wear distinguishable name tags.  I had no way of knowing whether I was talking to a senior R.N. with 20 years of hospital experience, a recent graduate of a community-college R.N. program, an L.P.N., or a "nursing assistant."  And, when I filled out the quality-of-care survey a month later, the only complaints I had were about errors and omissions by the nursing staff.

I do think teaching hospitals need to be careful about the degree of responsibility they assign to medical students. IMHO, there is no way two medical students should be doing cystocentesis on a patient without direct medical supervision by an experienced physician. 

My strangest "medical student" experience was many years ago, when I was a graduate student at a large university.  I was at the medical center to have blood drawn for something, and the guy doing the blood-drawing was acting nervous.  He explained that he was a 3rd-year medical student, doing a clerkship in that division of the medical center.  I thought he looked sort of familiar.  Turns out, he was.  He looked at me, and then at my paperwork, and said, "Weren't you a teaching assistant in Dr. "Z's" microbiology class 4 years ago?"  I said I was.  He said, "I was a student in that class!"  Then he proceded to pull the Vacutainer needle out of my vein without releasing the tourniquet first.  Oops.  Not bad, though -- just oops.

The thing is, mistakes and incompetence aren't limited to teaching hospitals.  I have some terrible stories about teaching hospital goof-ups, but some equally bad ones about mix-ups in community hospitals. The names change, but the problems don't.  Sometimes it seems like we need to stay awake and alert 24/7 while in the hospital, doesn't it?

otter 

I am also being treated at a teaching hosipital..but I do normally

request a board certified doctor in the speciality...sometimes

they are cross training so even tho they are board certified in

something it does not necessarily mean in the department

where you are being seen... 

The downside is that sometimes they tell you there is a longer

wait to be seen by a board certified doctor..

you can check out a doctor at

            www.abms.org

Raili ~ Why not ask  in advance when you make an appointment who you will be seeing and what the facilities policy is for having students, interns, residents etc treat patients. State that you want advance notice if anyone other than your doctor will be present.

Raili, I think I would have had the opposite reaction to yours.  My PCP uses lots of students in her practice.  Like your mammo dept resident, they usually come in first with their questions, taking notes and checking the site.  Then the doc comes in and asks if there are questions which I'm believeing is to make sure I got all the information.  So I would have said yes to the mammo resident as long as they were followed by the attending doc.  Only problem is since the attending is not in the room how can they know the resident covered everything? 

Now, the surgical resident is another story.  I don't have a problem with them being in the OR and "assisting" but your original post struck me with this statement:  "Oh, and there will be a [resident, doctor-in-training, I forget what word she said] assisting me with the surgery, but don't worry, I'll be there the whole time."    Why say you'll be there the whole time if the resident is only assisting?  Sounds more like the resident will be perforing the procedure with the attending watching/coaching - now there is where I have a problem.  I want "my" doctor to perform any procedure.  Let the resident practice on a blow-up doll, cadaver, whatever, but not me!

edited to add:  I fully agree with otter and the others that any hospital/doctor can and do make mistakes, teaching hospital or not.  That's one of the reasons malpractice insurance costs are through the roof.

great post, Southport. 

Linda - I actually had my Stage 2 DIEP in July - both the surgeon and the anesthesiologist addressed the "July new resident" issue directly with me before I even asked.  They said, for what it's worth, that in July the new residents are mostly observing and doing very little, and what little they are doing is VERY closely supervised - much more direct supervision than they get later in the year.  They both said that in my case the doctors would be handling my case personally, and the residents would be assisting only. 

Unfortunately, the issue of seeing NPs is not limited to teaching hospitals.  I love my onc - local private practice guy - but I'm now looking for a new one as the last two appointments I've seen an NP only.  When I questioned this, I was told that from now on if I want to see the doctor, I need to make a special request.  Needless to say, when I was choosing my medical team for my battle with cancer, I chose that onc for my medical team, not an NP. 

While the NP appears to be a competent NP, she's not an oncologist and has been unable to answer my questions to my satisfaction the way my onc could.  I'm extremely uncomfortable not having an onc actually see me and review my case with me, and be available to answer my questions.  I've requested my records and am now looking for a new onc - one that will actually see me.   Sigh. 

I also have been treated at a large teaching hospital.  On every occassion with a resident in training, my doctor asked for my permission prior to that person even being present in the room. There would be direct introductions by name and then what their role was in the exam or procedure.  My doctor or surgeon was always present.  I recall after my oophorectomy the observing resident stopped by to check on my pain management.  I feel this is a critical part of the teaching process but also as a patient that they interact with me directly.

What Sassa described sounds like a law suit IMO and the hospital was trying to avoid that situation.  That was truly a horrible experience for parent and child.

It's a matter of how they treat you. The morning after my mast, the surgical residents were doing rounds (that's the protocol where I was, my surgeon came later by himself) and wanted to examine me. There were about 6 or 7 of them, and I refused and said 1 could examine me, the rest had to leave. One of them said, "But we are all doctors". Duh. Like I thought they were the cleaning crew, getting curious. I very nicely told them to get out, and the one who was left was not pleased. She was not gentle with me, pressing on the dressing harder than was necessary. What was that about?  We then had an interesting conversation:

She: How do you feel?

Me: Very weak and dizzy. I passed out about half an hour ago.

She: I think you should go home today. 

(notice how she needs practive on her listening skills).

Me: The surgeon told me beforehand that I would be in the hospital for 2 nights following the surgery.  I feel very weak and dizzy and I PASSED OUT half an hour ago.

She: Well, we have to worry about hospital-induced infection.

 She then left my room. A little while later one of the nurses came in and said, "Oh, I hear you're leaving today. Your release letter will be at the nursing station soon. WHAT????????????? I got very upset and the nurse saw this. (mostly upset about the letter being ready - stopping any Israeli bureaucratic action in its tracks requires Superman, Spiderman, and The Incredible Hulk sometimes). When my doc came in later the first thing he said to me was"you're not going anywhere". He's the head of the department, so I'm sure there were repercussions for the resident.

OTOH, when I was readmitted with a post-surgical infection to the same hospital, I was quite pleased wih how I was treated. When the residents came around the first day I said the same thing about only 1 doc. The others left, and every day I was there they not only respected that but made sure that the same resident checked the infection every day. I overheard them explaining to  one of the doctors that I wanted privacy. No argument, just "this is why we're doing this".

Leah

NancyD:  I was really in need of a good laugh! Thanks!

TCK

It's really ironic that we're still having this discussion about "physicians-in-training," considering what happened at my doctor's office this morning.

I was at my primary care doc's clinic for a routine recheck, which he does periodically because of the meds he has me on (BP, cholesterol, thyroid).  It's a private practice with just one physician (boarded in family medicine), but my doc does have a nurse practitioner who helps with some of the really commonplace things.

Today, though, a 4th-year medical student walked into the exam room first.  She introduced herself, including the fact that she was a med student, and told me she was working with my doc. Having already looked at my paperwork, she said, "So, you're here for a medication refill?  Is there anything else you'd like to discuss or have us look at?".  I mentioned a couple of minor things, which she checked and wrote in her notes. After asking me a few more questions and re-checking some lab results, she said she was going to write up my prescription refills and talk to Dr. "X" about the new problems I'd mentioned.  A few minutes later, she came back in the room with Dr. "X" and the new prescriptions.  The three of us had a nice discussion about some new information relevant to my situation; and then I was done.

I really do think my visit was a good learning experience for myself and for the student. There is no way for someone to become a better doctor without lots of supervised, first-hand experience with patients. And that's what she was getting.

So, it's not just at teaching hospitals where we'll encounter medical students and residents learning how to practice better medicine.

otter 

[Edited to remove some of the irrelevant stuff.] 

All teaching hospitals play fast and loose with the disclosure. They can't out and out lie to you -  but they all have ways of phrasing things that aren't really lying, but conceal the truth of the residents & students involvement in your care. If they were honest about it - and humble - I wouldn't mind so much.

I can attest to the "trickery" at Hopkins. I had my mastx &  diep recon there.  I didn't realize until later how I had been manipulated. I saw my attending only once in hospital post op for about 30 seconds. the rest of the time it was the residents. I wish I'd thought at the time to limit the exam to only one of them. That would have been good. The worst was the morning the "fellow" came in. I think he expected me to curtsy or something the way he put quotes around the title "fellow" with his voice. Total @$$. Don't go to Hopkins unless you need their specialized skills. You'll get better care other places for general ordinary stuff - including cancer.

The resident who usually examined me every day didn't even look at me - just asked his questions and pulled down my gown to look at the flap and then pulled up my gown to look at the belly scar in front of like 6 men. No sense of decorum or dignity. Just another bunch of body parts - no humanity - lip service to dignity, but no attempt at actual human dignity. Given how truly hideous the first stage was I know it was probably the resident's first solo turn.