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02/06/2013

Paging Dr. Howser

Jennifer Chevinsky, B.S.

Hospitals in Adelaide, Australia had seen a young man looking like a doctor wandering hospital halls. Was this a case of Doogie Howser, M.D. – a fictional teenage doctor on a 90s television show – or something less benign? On February 1st, a 17-year-old Australian was arrested for impersonating a physician. He was arrested after treating a 12-year-old girl for minor injuries related to a scooter accident. The charges against him include administering prescription drugs, assault, and identity theft. As early as October, the seventeen-year old ‘physician’ had been found in hospitals across Adelaide, wearing scrubs and a name badge while confidently reading patient files. News sources report that two years ago he was dismissed as an ambulance volunteer, an experience that helped him to grow his medical familiarity and vernacular.

There are countless risks associated with an unqualified individual pretending to be a physician, writing prescriptions and suggesting treatment plans. Although this may seem like an unusual incident, in September an 18-year-old was arrested in Florida for the same reason, though this imposter dressed wounds, disrobed patients, and performed CPR. These rare cases raise related ethical issues: how do medical trainees identify themselves, what are their roles, and do patients have the autonomy to dismiss them?

In hospitals and clinics across the United States, patients are approached by many individuals with a range of expertise – from medical students to residents, fellows, and attending physicians. There are also a variety of interdisciplinary medical specialists – nurses, physician assistants, physical therapists, technicians, etc. In the past, there was an unwritten code that allowed those in the know to identify these individuals. Only physicians wore long white coats, medical students wore short white coats, surgical personnel wore scrubs, and everyone wore conservative business clothing. Today, one can finds nursing students wearing long white coats, physical therapists wearing scrubs, and physicians wearing jeans. For patients and practitioners alike, it is unclear who serves in which role.

As medical students, we are trained to introduce ourselves to a patient by name, rank, and serial number. For instance, “Hello Mr. Smith, I am Jennifer Chevinsky, a second year medical student at the University of South Florida Morsani College of Medicine.” The goal is to ensure that patients do not expect more of us than our training and the law permit and that as medical students, we are honest about our limitations. This practice begs the question as to whether all health care practitioners should announce their specific position, clarifying what services they can legally provide.

In line with concepts of truthfulness and proper disclosure, it is in the practice of most medical professionals to mention their role upon introducing themselves to a patient. My introduction usually precedes any questioning or attempts at eliciting a medical history. Whether I am wearing a white coat, scrubs, or business-casual attire, the patient is now oriented to my role on the team. When a patient stops me in a hospital hallway, calling “doctor” or “nurse,” I have grown accustomed to correcting their assumptions. Usually the patients are courteous and accepting of my position, but I have heard of patients dismissing medical students, demanding to see a “real doctor” instead; this occurs even though medical students are acting within their appropriate role by collecting a history. Do patients have a right to dismiss medical trainees in a teaching hospital? Does announcing my level of training make it more likely that I will be dismissed because patients may have a preconceived notion of medical students as “untrained” or in the case of those who watch medical dramas on television, “inept”?

In U.S. medicine, the concept of patient autonomy often trumps other ethical concerns. The medical student, physician assistant, and nurse are certainly qualified for their assigned tasks. And yet, all are often dismissed by patients who want “a real doctor.” Had each not disclosed their role, the patient might have been agreeable. Although I would not advocate for withholding information from patients, I believe there are limits to patient autonomy in this scenario. If a patient dislikes or distrusts a particular practitioner, he or she might be able to request to see a different one. For example, perhaps a patient cannot dismiss the category of nurse from their care, but if they have a problem with a specific nurse, another could be requested. This would be similar to the way patients interact with physicians. If resources allow, there should be some ability to switch nurses, medical students, physician assistants, etc. The limitation on autonomy is that we should not allow patients to climb the medical hierarchy, asking for the “real doctor” to provide services that others are competent and legally capable of providing.

If all patients requested only to see the doctor for every procedure and conversation, the system could not function. Furthermore, each individual on a particular medical team grows accustomed to his or her role and might very well be better at a specific procedure than the on-call physician. As care providers, we have the duty to disclose our roles prior to treating patients, so as to build trust in the practitioner-patient relationship. However, patients should not be able to dismiss a practitioner based on prejudiced beliefs about role-specific qualifications. The Australian teenager clearly endangered people’s lives by misconstruing who he was. Without legitimate role disclosure, patients could not know if he was an imposter or just another Dr. Howser. This case provides an opportunity to reflect on the importance of proper role disclosure in the medical field, while raising a discussion on patient autonomy and scope of practice.

 

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