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Is Physician “Shadowing” a Shady Practice?

 Shadows of people in a hospital hallway

I was startled to learn, when interviewing medical school applicants, that tagging along with a physician, or “shadowing,” is a common practice among high school and college students these days. Yes, I did say students as young as high schoolers.

Shadowing provides a way for students to observe at first hand what it is like to be a physician, and helps them decide whether the career will suit them. Medical school admissions committees look for activities such as shadowing as evidence that applicants have been exposed to medical settings, as confirmation both of students’ interest in medicine and of their understanding of the life of a physician.

​But as I spoke with premed after premed about their shadowing experiences, I became uneasy.

As a physician and a bioethicist, I started to wonder whether shadowing—while helpful for students and admissions committees—might potentially be harmful for patients.

The first time my ethical antennae were raised was when an applicant described his experience shadowing a gynecologist. I asked him whether any patients were reticent about having him in the exam room. He said no, but mentioned that he did feel a little awkward that the gynecologist introduced him to patients as a “student doctor,” and then let him watch them undergo pelvic exams. I wondered (to myself) whether these patients would have allowed the student to watch had they known he was a college student trying to decide about his career.

My curiosity about that question led me to examine the issue further. Just how does such a process fit into medicine, and what does it mean for doctors and patients? I examined shadowing in depth along with Michelle Goldsammler, M.D., in our paper “Physician Shadowing: A Review of the Literature and Proposal for Guidelines,” which was published in the January 2013 edition of Academic Medicine. Our goals in the paper were to review the literature to find out whether shadowing is effective, look at the ethical issues connected to it and figure out why people shadow physicians.

What we found troubled me. Of 770 articles in the literature from 1948 to 2011, we could find only 13 that specifically met our criteria for inclusion in the study, and only two of those examined shadowing exclusively. We concluded that more research is warranted and that objective outcomes would be useful. Guidelines on shadowing are needed and a code of conduct needs to be introduced for premed students to enhance consistency in shadowing and ensure that ethical and practical considerations are addressed.

Of course, ​there are other ways to find out what it is like to have a career in medicine. I know this because shadowing was not done in the Paleolithic age when I was in college. My exposure to medicine was primarily through my father, who was an ophthalmologist. I was keenly aware of his dedication to and love of his work, and impressed by the patients who came up to him in restaurants and stores to seize his hand and thank him for restoring their sight. I never witnessed him interacting with patients, though; I never followed him into the exam room. Maybe I was lucky; not everyone has a relative in medicine. To see doctors up close, I worked in the occupational therapy center of a psychiatric hospital, and participated in basic science and clinical research. I also was a candy striper. What’s a “candy striper?” you may ask. It’s a hospital volunteer from another era—but that’s a blog post for another time.

As far as physician shadowing goes, I have misgivings. I wonder whether patients are actually aware that high school or college students are present during their appointments with their physicians. Are the patients given the chance to decline? Even if given this opportunity, does the power imbalance in the physician-patient relationship inhibit them from saying no for fear of irritating their doctors? And if they do allow students into the room, do they share medically important but sensitive information? Might they neglect to mention rectal bleeding because they feel embarrassed at the thought of having a high school or college student present during a rectal exam? Do they omit discussing a concern about having contracted a sexually transmitted disease? Or not answer honestly about their alcohol consumption? Are these concerns outweighed by the benefit derived by premed students from being in the room? I suspect that students would respond in the affirmative.

But I am not sure what patients would say.

Have you ever shadowed a doctor as a premed or high school student? Did you find it useful? As a patient, has shadowing ever made you feel uncomfortable? Share your experiences by leaving a comment. 

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Elizabeth Kitsis, M.D.

Elizabeth Kitsis, M.D.

Elizabeth Kitsis, M.D. is director of bioethics education and assistant professor of epidemiology & population health and of medicine at Albert Einstein College of Medicine.

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Comments on this entry are closed.

  • Susanne January 8, 2014, 8:00 PM

    Physician shadowing? By college or even high school students? What fool thought this up? Do medical schools seriously require this now? It is a complete and total invasion of a patient’s privacy to have a person there, either in high school or barely out of it, who has zero formal medical training and who has not yet earned admission to medical school. I am glad I now know how little medical school faculty value us as patients and our privacy. It’s clear to me from reading this that academic medical centers and teaching hospitals will stop at nothing to invade our privacy as patients. This is absolutely disgusting.

  • VKA January 9, 2014, 12:59 AM

    I have to say, a drive to develop regulations and guidelines is admirable, but it will end up reinforcing the class divide and keep disadvantaged students from medicine. I come from a medical family, and I was able to shadow my uncles and aunts with literally zero paperwork- they were willing to go to bat for me and have me in their offices and ORs. But a student who has no connections, no uncle or aunt, who doesn’t come from the social class that includes doctors? They have a hard enough time as is. Imagine what it would be like if a potential doctor to shadow had to fill out reams of paperwork (and yes, it may just be one form, but the perception of work will still be enough to deter physicians). I would advocate letting things be, and leaving shadowing to individual doctors’ judgement.

    Shadowing is critical, and shadowing before college is quite appropriate if one is applying for one of those 6-7 year guaranteed medicine programs straight out of high school.

    In this era of high burnout and physician dissatisfaction, it is critical to know what a doctor does before spending several hundred thousand dollars on an education, and being locked in. The more exposure the better.

  • SM January 9, 2014, 3:54 PM

    At most medical schools, shadowing is an unspoken requirement. At some schools, like University of Washington, it is clearly stated that the admissions committee expects a minimum of 40 hours shadowing physicians prior to applying. In pre-med math, that means the minimum is at least 80 hours spread across a variety of specialities.

    Besides zero data demonstrating that shadowing is beneficial (or at least not harmful to patients), it’s yet another crutch for affluent students with professional parents. The median household income of matriculating medical students is at $120,000 and rising every year! Most doctors either don’t respond or invoke the all-purpose HIPAA smokescreen when confronted with the possibility of introducing a know-nothing pre-med to their craft…unless, of course, it’s their relatives or relatives of colleagues doing the asking. Some students have the benefit of well-structured shadowing/internship programs at their universities, but most don’t.

    Adding more and more unspoken requirements to the pre-med checklist that are far easier for the wealthy and connected to achieve only broadens the divide between Joe Average-Patient and the physicians who serve him.

  • Carolyn Thomas January 10, 2014, 3:59 PM

    I had to go have a wee lie-down after reading this, Dr. K. As a heart patient who’s also become a frequent flyer of our healthcare system, I am utterly gobsmacked that high school students (did you say HIGH SCHOOL STUDENTS?!) would be allowed within a mile of a patient, never mind a patient’s pelvic exam. (Did you say PELVIC EXAM?!)

    And to have the gall to introduce such an observer as a “student doctor” is not only a lie, it’s deliberate fraud on the part of the doc doing the introducing. Why is it necessary to lie? Because any physician who’d initiate such a lie knows full well that high school kids (or pre-med college kids who have not yet even been admitted to med school) do not belong in the middle of such a personal and intimate doctor-patient interaction.

    There’s also the unspoken inherent power imbalance that’s always present in this relationship. Even asking “Do you mind?” questions of a vulnerable, sick patient does not guarantee an honest reply. Patients are known to agree to requests from their physicians that they would not agree to coming from anybody else. An interesting study published in Health Affairs in 2012 found that even subjects described by researchers as “wealthy and highly-educated” (from Palo Alto, California) reported extreme reluctance to be seen as “difficult” in front of their physicians. These are precisely the kind of patients who would likely answer: “No, of course I don’t mind, Doctor!” when asked if this “student doctor” could sit in.

    For the benefit of those commenting here who were lucky enough to play your family or status card in arranging your own shadowing gigs (without all that pesky ‘protection of privacy’ paperwork), here’s a news flash: this isn’t about you.

    This isn’t some fun “Take Your Kid To Work Day” exercise to see if you’d like to be a golf pro or a stockbroker or a bus driver when you grow up. These are Real Live Patients undergoing diagnostic tests and/or medical procedures with all accompanying discomfort, anxiety and distress that patients know all too well.

    Want to “know what a doctor does before spending several hundred thousand dollars on an education”? Go look it up on YouTube. We patients are not here for your entertainment.

    • VKA January 12, 2014, 11:03 AM

      With all due respect Ms. Thomas, you misunderstand my point.

      No matter what regulations are developed, those like me with family connections will still be able to shadow- our relatives will likely be happy to fill out whatever forms are required and let us into their offices. It is only those without such connections who will ‘suffer’ should regulations come to pass. I agree that pelvic exams are rather extreme, but to my knowledge no doctor would let any shadower near one. If a doctor does, then that doctor’s patients probably have bigger problems than a shadowing high schooler sitting in on their exams. And speaking of high schoolers- if you call 911, there’s a decent chance than an 18 year old EMT will be the one taking you to the hospital. Age is no guarantee of maturity, and youth is not necessarily a marker of the opposite. It should be left to individual doctors to determine if the individual student in question is ready to shadow.

      While you are correct that there is a power-imbalance, there is also an obligation: training the doctors of the future. If you plan on living for another 20 years, that high schooler may become your PCP, or cardiologist, or general surgeon. Do you want to be treated by a burned out shell of a human being who hates their job and just wants to get through each day so they can get drunk at home? The likelihood of such an outcome is increased, should bright-eyed young students go into medicine with no idea of the very real sacrifices (and pleasures) involved. Youtube, and all those crappy medical dramas do nothing to convey the pleasures or the pain of medicine.

      To my recollection, the Health Affairs article you mentioned fails to take into account an important factor- patient guilt about not providing for the future. After all, it is our children who will suffer most should those patients refuse shadowing pre-meds. The only mechanism studied for patient discomfort was concern about being seen as a difficult patient- not patient guilt about being publicly seen selfishly refusing to help future generations of doctors.

      I understand your concern, but I ask that you trust your and other physicians to make appropriate choices. After all, considering what doctors are already trusted with routinely, isn’t this a minor addition? For the sake of preserving access to medicine as a career for thousands of minorities, and for training future doctors who will take care of us and our children, I would suggest that regulation would only be counter-productive.

      • Susanne January 15, 2014, 2:48 PM

        “I understand your concern, but I ask that you trust your and other physicians to make appropriate choices.”
        That is paternalistic medicine. The worst possible thing any patient could ever do is surrender their own decision making and to trust their physician to make appropriate choices without the patient’s input. I am not a child, nor are other patients. I make my own decisions and if I do not want my physician’s nephew in my exam room or OR because he is trying to decide what he wants to be when he grows up then that is the way it is. Were those patients in the OR aware you would be there? Did they give specific informed consent? Were you introduced to them?
        “Do you want to be treated by a burned out shell of a human being who hates their job and just wants to get through each day so they can get drunk at home? ” That is alarmist. If I deny a high school or college student the ability to sit in on my doctor visit it does not mean that I am selfish and placing future generations at risk of being treated by drones by day and alcoholics by night. In addition to being bad for patients, shadowing does little to help potential doctors. I agree that anyone contemplating a career in medicine needs to be aware of what it entails. A structured internship or volunteer program is a great way to accomplish this. Sitting in on doctor visits just reinforces the “Hey look at me!” attitude that is so prevalent among young people day. If all a prospective medical student has to do is show up and tag along, then that in no gives them a realistic view of a career in medicine and the HARD WORK they need to be prepared for.

  • Ed January 10, 2014, 8:35 PM

    This is a reprehensible practice in the absence of true prior informed consent. Its obvious that medical “professionals” (sarcasm intended) do not subscribe to any common basic medical ethics as evidence by this practice and others (pelvic and prostate exams on anesthetized patients by “students”). Patients do have the ethical and legal right to choose who and to what degree a provider (physician, PA, NP, nurse, medical assistant, student, or chaperon) participates in his or her healthcare, even in a teaching hospital. We are after all the patient and customer actually paying for a service. I insist providers participating in my healthcare introduce themselves, cite their professional qualifications, and justify their presence by clearly explaining their role and how I benefit. If unconvinced, I politely but firmly simply say no!

  • Rob February 17, 2014, 2:31 PM

    As a med student who did premed shadowing (trauma surgery, pediatric anesthesiology and pediatric GI) I am offended by this article. Shadowing was an eye opening experience, it solidified my desire to become a physician. Not to mention, it is an unspoken rule that you have to do it now a days to be accepted. Plus, there is a big difference between shadowing an outpatient clinic and observing pelvic exams. I never felt uncomfortable shadowing and I don’t think any patients (or the patients families) ever felt uncomfortable. I was almost always greeted with a smile.

  • Jackson David Reynolds June 9, 2014, 11:32 AM

    As a pre-medicine student in his junior year of the rigorous undergraduate study required for any hope of acceptance to medical school, I can comment from personal experience that physician shadowing for pre-medicine (or even perspective pre-medicine) students is truly a wonderful thing. Early in my high school career, I knew that I wanted to pursue a career as a physician, though I was unsure which specific area of specialization I wished to enter as a doctor. During my sophomore year of high school, I began shadowing emergency physicians at my local hospital’s emergency department for full 12-hour shifts twice per week. Over the course of 18 months, I shadowed this group of 7 physicians for more than 1,300 hours and learned an immense deal, not only about medicine as a practice, but I also gained intimate knowledge about the trials and personal challenges faced by physicians on several fronts. After finishing this unofficial “internship” in emergency medicine, I went on to shadow another 1,000+ hours in the fields of internal medicine, general surgery, anesthesiology, otorhinolaryngology, and maxillofacial reconstructive surgery. Through these experiences, I have had hundreds of hours of patient contact/interaction, befriended several superb physicians/surgeons, and gained a MUCH better understanding of the life of a doctor, and what each of these fields specifically entails for one, than I ever would have been able to do without these invaluable experiences. My thousands of hours shadowing physicians has served only to increase my passion for and interest in the practice of medicine, and I also feel much more prepared to pursue both the academic and clinical aspects of medical school because of them. Physician shadowing is not at ALL a “shady” practice. It is an invaluable tool which allows the doctors of tomorrow to gain the best footing possible for their future careers, and it firmly solidified my desire to pursue a life practicing the noble art of iatrology. It would be a mistake to choose to pursue a career in medicine without first having had at least some manner of experience in the field to give one a taste of what life as a doctor is truly like. The road to becoming a physician, as I well know, is a long and difficult one – one best travelled with a good map and a skilled guide. The relationships I have fostered and the experiences I have been allowed to have through my extensive time shadowing numerous physicians over the past four years have provided me with both of those things.