Author: Aaron Dora-Laskey, MD
Central Michigan University College of Medicine
Editor: Rahul Patwari, MD
“Did you hear about Dhivya?”
A group of medical students are having coffee in the auditorium lobby before grand rounds. The night before, one of their colleagues was admitted to the ICU after an intentional overdose of prescription sedatives.
Student #1: I read on Facebook that she was intubated after taking 20 tablets of clonazepam.
Student #2: I was working in the ER last night when she was arrived. Her roommate found her unresponsive at home. EMS gave her 4 mg of naloxone, but she didn’t respond. I think she was panicking about the dermatology match. I heard she only got four interviews.
Student #1: Dhivya’s been going through a lot since her mother’s been sick. Her brother took a leave from law school to help at home, but I know she’s been stressed out. I never thought she’d try to hurt herself, though. Do you think she was using any other drugs?
Student #2 (looking at his tablet computer): I can log into the EHR and check her toxicology screen.
Student #3: Are you sure we should be looking at her medical records?
What issues does this scenario raise? What information should the students share, if any, about their colleague? Under what circumstances should they access this patient’s medical records?
This self-study module, we will discuss these and other professionalism topics. Upon its completion, you should be able to explain the importance of the following behaviors as they relate to the role of medical students in the ED:
- Maintaining respect for patient complaints
- Maintaining confidentiality
- Punctuality and appearance
- Respecting patient autonomy
- Being respectful of colleagues
- Sensitivity to patient differences
- Accepting constructive feedback
- Abiding by policies and procedures
- Honesty with patients and team members
Professionalism is the basis of medicine’s contract with society, a tacit pact in which physicians’ privileges are contingent upon their ability to demonstrate competence, exercise moral responsibility, and place their patients’ interests ahead of their own. As student physicians in the emergency department (ED), you are tasked not only with mastering the cognitive and technical skills requisite for successful medical practice, but perfecting the attitudes and behaviors that will prepare you to provide compassionate, respectful, and high quality patient-centered care.
A number of pitfalls to the successful practice of professionalism are lurking in the ED, however. The first among these that should be confronted is cynicism. Patients present to the ED in various crises 24 hours a day, whether they’re of a medical, surgical, psychiatric, or social nature. While the majority of these crises are handled with sympathy and tact, some are confronted with skepticism, neglect, or even contempt, especially when they involve substance dependence, sexually transmitted infections, or other complaints attributed to perceived lapses in “personal responsibility.”
It cannot be overstated that the role of the ED treatment team is not to determine a patient’s personal culpability for their illness or injury, but to provide relief from suffering while swiftly identifying life- and limb-threatening disease. (We do not, for example, treat the overweight, middle-aged smoker with an acute MI differently than the younger patient with familial hypercholesterolemia.) Most experienced ED physicians have been humbled by the “drug-seeker” whose back pain emanated from an unrecognized ruptured AAA, or the “drunk” parked in a hidden hallway corner who was later discovered to have a subdural hematoma.
After recognizing that every patient complaint is deserving of respect, we must also acknowledge that the opportunity to care for patients is a privilege. We treat Broadway actors who’ve fallen from stage rigging, and undomiciled patients in the throes of untreated psychoses. We care for daring professional athletes felled by gravity, and alcohol-fueled misadventures by their amateur imitators. Whether titillating or dull, frightening or sorrowful, we are obligated to treat all of these patients’ stories with the utmost confidentiality.
And while these tales may be attractive as fodder for short stories or cocktail party patter, it is important to remember that the relationship between caregivers and their patients is inherently sacrosanct. Even anecdotes stripped of specific identifying information may be revealing, and it is critical that details of ED patients’ care be shared with others only when it’s germane to their treatment. Once a patient leaves the department, any further access to their records must be strictly limited to short-term follow-up for educational purposes. Lastly,details about patients or their care should never be posted on social media.
In the following vignettes, we will illustrate several other important tenets of professionalism as they relate to the roles of medical students in the ED. While these are not meant to be comprehensive—dozens of competencies have been enumerated under the rubric of medical professionalism—they are designed to inspire critical thinking about how best to provide competent, equitable, and humanistic care to the acutely ill or injured person in the emergency department.
Scenario #1: Pizza Shack
Resident: Hey, where were you? We just intubated your patient in bed #1—we couldn’t find you anywhere.
Student: Oh, I walked over to the Pizza Shack to get some lunch. I was starving.
Resident: It’s 11:30 am, and our shift started at 9:30. Didn’t you eat breakfast?
Student: I can’t remember, honestly—I’m still hung over from our trip to the casino last night. I’m pretty sure I forgot to shower this morning…and these are definitely not my socks.
Resident: Well, you look terrible. And you smell terrible. Next time, please let me know if you need to leave the department for any reason. I expect you to show up clean, rested, and ready to work.
The skills of professionalism are manifold. Some of these, like timeliness, may seem self-evident, but are easily thwarted by alarm clock failures, weather emergencies, and fickle traffic patterns. As a student rotating in the emergency department, you’re expected to arrive promptly, and stay until your documentation is completed and your patients are discharged, admitted, or handed off to the next shift.
Hygiene, too, may be taken for granted by adult learners, but how many species of staphylococci could be cultured from the sleeves of your lab coat? Is the alcohol-based skin cleanser affixed to your buttonhole likely to exterminate the C. difficile spores from room #7? While ED uniforms vary in color and style, your attire should be clean, neat, and adhere to the dress code of the institution—as well as be free from interloping bacteria.
It is understood that medical students, as living creatures, have biological needs that must be attended to periodically (e.g., eating and sleeping at regular intervals). It is exceedingly difficult to differentiate the causes of acute encephalitis when you’ve skipped breakfast and can only focus your thoughts on the unit clerk’s poppy seed muffin. Similarly, sleeplessness will limit your ability to master new information and skills, and it increases the chance of you making a mistake that could potentially result in patient harm.
In summary, while there may be unforeseen barriers to punctuality and sleep hygiene alike, carefully planned sustenance, rest, and attention to your appearance will allow you to perform to your greatest potential. Perfecting these habits as a medical student will bolster your personal satisfaction and career longevity in your chosen specialty.
Scenario #2: Rule-out meningitis
Resident: There’s a college student in room #12 with fever and neck stiffness. Have you done an LP yet?
Student: I’ve only practiced on a task trainer in the simulation lab.
Resident: Well, now’s your chance. I’ll get the equipment.
Student: Is the patient okay if I try?
Resident: He’s pretty confused—I don’t think he’ll know the difference.
Student: Does he have any family with him I could talk to? I’m not sure I’m ready to attempt this on an actual person.
Resident: Suit yourself, but most students would jump at this chance. Didn’t you tell me that you were applying to this program?
In the ED setting, scenarios do arise in which students may not have an opportunity to properly obtain consent for their participation in patient care (for example, doing chest compressions during CPR). In such cases, the benefit of student education must be weighed against any potential harm to the patient. These calculations can be challenging. Some students may be blinded to these dilemmas by their excitement about performing a new task. Others may fear that bydeclining such opportunities that they will be perceived as disinterested (and lose out on future chances).
In most circumstances, however, consent can be obtained, and students should seek the permission of patients (or their parents or caregivers) prior to attempting a new procedure. This should include honest answers to questions regarding the student’s preparation and abilities, as well as the impact of the student’s experience level on the procedure (in terms of increased time and discomfort, or decreased rate of success).
When weighing the decision to attempt a new procedure in the ED, it is prudent to ask two questions:
- Are you cognitively prepared to perform the task?
- Do you know the steps of the procedure and the relevant anatomy? Have you observed the procedure before? Are you familiar with the requisite technical abilities (e.g., sterile technique and local anesthesia)? Have you practiced in a simulated setting?
- Is the procedure necessary for your professional repertoire?
- For example, if you’re planning a career in adolescent psychiatry, it’s unlikely that you’ll need to perform a cricothyrotomy. If it’s relevant, is it an important skill for you to learn prior to commencing residency? However enthusiastic you might be about evacuating a hemothorax in a pediatric trauma patient, residency program directors do not expect you to graduate medical school with this skill.
When caring for sick and injured patients in the ED, we are tasked with balancing the patient’s autonomy with our notions of beneficence and malfeasance. As students, you have the right to be educated. However, the obligation to educate you belongs to your university’s faculty—not its teaching hospitals’ patients. Through honest, open communication that demonstrates a respect for your patient’s informed decision-making, you are more likely to gain their trust and build relationships that are mutually beneficial—to their health, and to your education.
Scenario #3: Hemoglobin electrophoresis
One of the second-year emergency medicine (EM) residents is presenting the case of a patient complaining of cough. The patient was initially interviewed and examined by the visiting 4th-year medical student.
Resident: This is a 34 year-old man with a history of sickle cell disease—
Student: Sickle cell beta thalassemia. Would you like to review the electrophoresis report?
Resident: Sorry, sickle cell beta thalassemia…who is presenting with upper respiratory symptoms.
Student: He actually has symptoms referable to both the upper and lower respiratory tracts.
Resident: Anyway, he’s presenting with one day of rhinorrhea and cough. He reports that his daughter was evaluated in the peds ED yesterday with croup—
Student: Laryngotracheobronchitis, specifically. I saw her with Dr. Nathan and diagnosed the patient myself. The diagnosis was easy to clinch, as I spent the summer after my sophomore year in college researching parainfluenza viruses in rhesus monkeys. As you might recall from my curriculum vitae, I was the fourth author on a paper published in the Icelandic Annals of Simian Virology.
Resident: Well, he hasn’t had a fever, but—
Student: We must disclaim, of course, that the triage measurement was obtained utilizing an axillary probe. I would recommend repeating this measurement with a rectal probe in order to achieve a greater degree of accuracy. In anticipation of such a scenario, in fact, I arrived an hour early this morning to calibrate all of the rectal thermometers in the ED.
Attending (whispering to the resident): I’d ask how, but I suspect I’ll regret it.
Everyone wants to project their best selves when they’re being evaluated, and medical students are no different. Indeed, they are often asked to confront a common and frustrating paradox: They must demonstrate insight into their patients’ conditions to a degree that demonstrates the adequacy of their examination skills and medical knowledge, yet they must do so without appearing to interrupt, undermine, or contradict fellow trainees, supervising physicians, or ED staff.
Team-based models of health care have upended some of the more rigid hierarchical structures once common in medicine. However, the nurses, doctors, medics, and therapists caring for ED patients—like trained professionals in any setting—are rightly proud of their abilities and accomplishments, and may be sensitive to perceived criticisms (implicit or explicit) from less experienced members of the treatment team.
Allowing sufficient time and space for others to work, listening actively, and speaking in turn are all successful strategies for integrating oneself into activities of the emergency department. By understanding and respecting the boundaries between levels of professional training, students are better able to integrate themselves into the treatment team. Further, these habits will often result in the dividend of good will from colleagues and co-workers.
Scenario #4: Acute Abdominal Pain
Student: Can we order some morphine for Ms. Hernandez in bed #7? She’s very uncomfortable.
Resident: The 50 year-old woman with abdominal pain? I thought she was overly dramatic. Let’s try Mylanta®—it’s probably GERD.
Student: I’m really worried about her. She’s diaphoretic, her white count and lactate are elevated, and she stopped her warfarin last week for a dental procedure. She could have mesenteric ischemia related to her atrial fibrillation.
Resident: Her abdominal exam was pretty benign. Hispanic patients are usually dramatic, but they never have anything wrong with them. It’s the Chinese patients you should worry about—they’re very stoical.
Whether consciously or unconsciously, our preconceived notions about gender, race, ethnicity, socioeconomic class, and religion—among many other differences—color our perceptions of patients’ complaints. Multiple studies have shown that people of color with long bone fractures, for example, may be less likely to receive adequate ED analgesia. Even when stereotypes like the ones above are not rooted in racial animus, they often distract us from trying to genuinely understand a patient’s chief complaint its probable causes.
There are, of course, ways in which understanding geographical, linguistic, and cultural differences may help us provide better care to ED patients. “Dizziness,” for example, may mean different things in different languages and cultures. Understanding the global distribution of sickle cell disease, you may be less surprised when a patient complaining of a pain crisis turns out to be a student from Saudi Arabia. Knowing that some recently immigrated groups may be at higher risk for tuberculosis may help you better identify afflicted patients, especially when they present atypically.
Most of us believe that our practices are blinded to differences of age, gender, and ability. However, our patients’ experiences often contradict this: elderly patients are often infantilized (with names like “sweetie”); transgender patients report hurtful language by nurses and physicians; providers fail to ask wheelchair-bound patients with genitourinary complaints about sexual activity. By first recognizing the (often subtle) ways in which patient differences affect their ED treatment, we are better able to provide all of our patients effective, high quality care.
Scenario #5: Saved by the Bag
Resident: How did the rest of the laceration repair go in room #10?
Student: Why? Did you not think it was going well? It didn’t look good?
Resident: No, your closure was very elegant. But you could probably have used fewer sutures to achieve the same outcome.
Student: Oh, man, I’m so sorry. Was it that bad?
Resident: No, really, the wound closure is excellent. But you were in that room an hour and a half repairing a 3 cm finger laceration—you missed two level I trauma activations and a STEMI alert.
Student: Man, I suck. I can’t do anything right.
Resident: Listen, that’s not at all what I’m saying–
Student: This is just like the time I dropped the newborn on OB.
Student: It’s okay—it landed in the plastic bag. I wiped the schmutz off, but the parents freaked out.
Resident: I can imagine they might have. Let’s get some bacitracin and gauze for that finger.
Evaluation is fundamental to career development. From daily shift evaluations to monthly clerkship grades to high-stakes standardized board examinations, students’ performance is periodically and systematically critiqued. The purpose of this feedback is not solely for clerkship directors (and future residency program directors) to rank students against their peers, but to provide students with qualitative and quantitative measurements meant to reinforce gains in knowledge and skills, and to identify areas where improvements can be focused.
By being receptive to criticism in its many forms, students are best able to participate in constructive dialogues with their instructors, facilitating the transference of specialty knowledge, institutional culture, and best behavioral practices. Resistance to these measures—belittling suggestions for improvement, naysaying constructive criticisms, and ignoring poor grades—leads to alienation from institutional values, weakening of knowledge, and failure to attain expertise.
Evaluations are an integral part of any medical career. The evaluation process is no less intense during residency training, and continues throughout your professional tenure. You will be evaluated periodically by your specialty’s licensing body over the course of your career, and you can expect to be regularly evaluated by future employers and medical staffs. Most institutions now require that you participate in customer satisfaction surveys, and web-based patient surveys continue to proliferate online. By embracing evaluations as a natural part of the development process, you will better realize your goal of becoming a competent, knowledgeable physician.
Scenario #6: Pad Thai
Student: Hey, I was wondering if I could work an extra shift with you tomorrow.
Clerkship Director: I did see your email about that. I also got your voice message, your text message, and the sticky note you left on my office door. I also noticed that your phone number was etched in the condensation on my office window.
Student: Did you like the smiley face?
Clerkship Director: As stated in the student handbook, we are unable to schedule additional shifts. I appreciate your enthusiasm, but we have a very limited number of slots during which we can accommodate rotators, and it’s just not fair to the many other students in the ED this month.
Student: Well, I really want to get a good SLOE from this program. Do you have any research projects I could help with?
Clerkship Director: We have several projects that might interest you. Did you apply for our research elective?
Student: Sorry, I don’t have time. I’ve already scheduled five more EM rotations, and I’m spending September in Saskatchewan on a medical mission. Plus, I’m the captain of the medical school’s quidditch team—we’re preparing for regional competition next month.
Maybe I could wash your car?
Clerkship Director: I commute by bicycle.
Student: I can wash your bike. Do you like pad Thai? I’ll make you dinner!
Clerkship Director: Sorry, I’m hypersensitive to ground nuts.
Student: I’ll bring you cupcakes!
Clerkship Director: No, please, that’s not necessary.
The next day, as the clerkship director nears the end of her shift…
Student: Hey, how was the commute? I hope you didn’t forget your helmet!
Clerkship Director: I didn’t realize that you were scheduled this afternoon.
Student: I wasn’t. Do you want a cupcake? They’re lemon-frosted!
Clerkship Director: I thought we had discussed scheduling extra shifts.
Student: We did, but the afternoon attending told me it was okay if I worked with him. He loves Thai food!
For students interested in applying for residency programs in emergency medicine, 4th-year rotations may be especially stressful. Each shift can feel like a mini-audition, where case presentations are criticized for duration and content, laceration repairs are inspected with minute detail, and hours of studying may feel upended by a single, unexpected follow-up question by the senior resident about the intrinsic coagulation pathway.
In this stressful, competitive environment, it is not unusual or surprising that students may want to distinguish themselves from their peers in order to attain or maintain a competitive advantage. This may take the form of switching shifts to work with program directors or department chairs, seeking out individual letters from esteemed research faculty, or arranging multiple meetings with department administrators in the hopes of procuring valuable “face time.”
While none of these behaviors is necessarily forbidden, the residency program directors and clerkship directors in emergency medicine are keenly interested in providing balanced, equitable experiences for all of their rotating students, and have developed policies to ensure this. Further, given that the substantial majority of applicants to emergency medicine programs are successful, the students you’re ostensibly competing with today are very likely to be the colleagues you’ll be expected to collaborate with in the future. By focusing clearly on your job as a student—learning—you can best accomplish the goal of the EM rotation: becoming a successful physician.
Scenario #7: Teflaro®
The resident and medical student are reviewing a CT at the PACS station. They have just spoken to the oncology fellow about a patient with fever one week following chemotherapy, and are reviewing his chest radiograph.
Nurse: Can you guys come into room #4? I think your patient with neutropenic fever is having an allergic reaction.
Resident: It’s probably “red man syndrome” from the vancomycin.
Nurse: He’s only gotten the cefepime so far.
Resident (to the student): I thought you said he was only allergic to Telfa dressings.
Student: No, I said he was allergic to Teflaro® (ceftaroline), the 5th generation cephalosporin.
Resident: That would explain the pharmacy warning I overrode when I ordered it. Let’s go see how bad it is.
They examine the patient, who has generalized urticaria, but no angioedema; his blood pressure is normal. The cefepime is discontinued and the patient is successfully treated with antihistamines.
Student: Did you explain to the patient what happened?
Resident: No way—that’s just asking to get sued. Anyway, it wasn’t a serious reaction. He’s fine after 50 mg of Benadryl.
Given the number of rapid and nearly simultaneous patient care-related decisions ED providers must make every shift, some mistakes are inevitable. While systems are constantly being recalibrated to prevent errors, it is important that—in addition to recognizing, addressing, and working to prevent these from recurring—these mistakes be disclosed to supervisors and patients alike.
There has been much written on whether and when to inform a patient or their family member about a medical mistake. While the particulars of how to best disclose such errors may depend on the particular circumstance (including the perceived harms), local practice, and institutional protocols, there is little question that honest disclosure is generally the best course of action. And it is surely the case that these types of errors must be immediately reported to one’s supervisor.
Honesty, of course, is not only a good policy as it pertains to informing patients about treatment errors. It is also important to maintain the same vigilance when it comes to medical documentation, as well as in interactions with fellow students, ED staff, and supervising physicians.Such openness is critical to establishing credibility.
As a medical student, there are a multitude of behaviors specific to your role as a learner in the ED, as well as ones that are generalizable to your development as a resident and attending physician. As you master many of the professionalism competencies discussed in this module (e.g., punctuality, maintaining confidentiality, disclosing errors) and develop a greater depth of ED experience, you will have opportunities to address higher-order issues of professionalism. These may include: recognizing and avoiding resource over-utilization (e.g., in ordering CT scans for minor head injury or antibiotics for viral upper respiratory infections); defusing conflicts with admitting physicians and consultants; and recognizing and addressing substance dependence by your colleagues.
Perfecting the behaviors of professionalism is a career-long endeavor. Potential pitfalls to your success may be present in every patient interaction, test ordered, treatment planned, or specialist consulted. Through careful observation of the best practices by your peers, modeling excellence by physician mentors, thoughtful self-critique, and attention to evaluations of your performance, you can develop the tools necessary to succeed as a professional in emergency medicine and beyond.
Case Resolution (“Did you hear about Dhivya?”)
Student #3: I know everyone’s worried about Dhivya, but her medication list and test results are protected health information. I don’t think that sharing it with each other here is likely to help her medical care.
Student #2: You’re right (putting tablet away). I think I just got wrapped up in the excitement of the case. Has anyone talked to her family yet?
Student #3: I’ll call her brother this afternoon. Do you guys want to come with me to see her in the ICU after conference?
Student #1: Of course. I’ll meet you there after simulation lab.
Student #2: And I’ll pick out some flowers and a card.
Spandorfer J, Phol CA, Rattner SL, and Nasca TJ. Professionalism in Medicine: A Case-Based Guide for Medical Students. New York: Cambridge University Press, 2010.
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med.2002; 136: 243-246.