Exploring the effects of medical trainee naming: a randomized experiment

Undergraduate medical trainees are increasingly engaging with patients during preclinical years. Direct exposure to patient care during the first and second years of medical school, once considered an innovative method to keep trainees engaged during preclinical years [1, 2], is now a selling point at medical schools throughout the United States. In their report titled Medical Student Involvement in Patient Care, the Council on Ethical and Judicial Affairs of the American Medical Association’s Opinion 8.087 states that ‘patients should be informed of the identity and training status of individuals involved in their care and all healthcare professionals share the responsibility for properly identifying themselves.’[3] However, evidence from multiple health systems suggests patients are often not able to accurately identify important information about their healthcare team [4‐6]. With many medical school curricula including early and frequent exposure to actual patients, making medical trainees more pervasive members of the healthcare team, revisiting one component related to the aforementioned issue is now necessary.

The question of how an undergraduate medical trainee should identify him or herself to patients has garnered only fragmented discussion to date [7‐10]. Unlike those in other fields, [11] medical professional associations have not offered strict, standardized guidelines on how medical trainees should introduce themselves. Because of this, a variety of titles for medical trainees in medical school, including ‘medical student,’ ‘student doctor,’ and ‘student physician,’ are currently used without any recent, rigorously obtained evidence [10].

While naming may seem like an exercise in semantics, Silver-Isenstadt and Ubel [10] found that the aforementioned titles are not equivalent from the patient perspective. The patients surveyed understood ‘medical student’ as those trainees with the least amount of clinical experience, while ‘student physician’ connoted those trainees with only slightly less experience than ‘house staff.’ This difference suggests the issue of ensuring patients are capable of providing proper informed consent to be seen by a medical trainee requires an understanding of titles. As such, a rigorous exploration of the effects of medical trainee titles on patient perceptions is warranted. This includes elucidating how providing patients the information that is supposed to be conveyed by a title may affect perceptions.

Thus, the aim of this study was to provide the first evidence-based answer to the question ‘how should undergraduate medical trainees introduce themselves?’ To do this, we first aimed to characterize the general population’s perception and understanding of trainees using the three aforementioned titles. We then aimed to explore how the general population’s reported comfort with being examined by a trainee differed before and after being educated about the true education level and responsibilities of medical trainees.

Overall, medical trainee title was not found to have any effect on subjects’ reported comfort with being examined or with their perceptions of trainees’ responsibilities and education, though there was a non-significant relationship between lower comfort levels and the student-physician scenario. However, informing subjects was found to increase reported comfort with being examined by a medical trainee.

Concerning preferences for medical trainee title, almost half of subjects reported preferring the title medical student. However, subjects were significantly influenced towards preferring the title initially presented to them in their respective randomization group. This finding may in fact corroborate findings elsewhere: (1) patients often find it difficult to say ‘no’ due to hierarchical power dynamics in the healthcare provider-patient interaction [17] and (2) patients adopt what they are presented as an act that symbolizes ‘deference and demeanour’ to medical authorities [18]. This suggests that title itself may be less important than using said title consistently.

Concerning subjects’ perceptions of medical trainees, this study suggests that subjects have a general understanding of the medical trainee level of education and that this understanding is consistent across titles that might be used by medical trainees. Subjects believed medical trainees had, on average, 6.14 years (SD 2.97) of post-secondary education and 2.90 (SD 1.77) years of medical education, which aligns with most medical trainees in clinics having had a 4-year bachelor degree and being within their third year of medical school. Subjects seemed less well-informed of medical trainee responsibilities, though this was also found to be independent of medical trainee title. Of the subjects, 50.2 % believed medical trainees have certification or licensing, 7.9 % were unaware that medical trainees are bound by the same confidentiality standards as their physician counterparts, and 15.3 % believed medical trainees have the ability to prescribe medication. The fact that half of all patients believe medical trainees have some kind of certification or licensing suggests the public may not be truly informed about the background of members on their care team. Marracino and Orr [7] suggest that medical trainees might use the term ‘student physician’ only after passing United States Medical Licensing Examination Step 1 and Step 2 (clinical knowledge/clinical skills) in order to better educate patients to their trainee level, yet our study suggests that naming alone is not enough to inform patients of differences in trainee licensing and responsibilities.

Finally, this study highlights the importance of studying the impact of providing potential patients with more complete information about medical trainees. We live in an era of medicine that is torn between the ideals of decent care [19, 20] and the actual practice of patient care, which complicates the informing process. On some teams, medical trainees ‘suffer an erosion in their attitudes about telling patients they are students’ [8] while on others students are ‘introduced to patients as “doctors” by members of the medical team’ as a way to avoid patients refusing medical trainee care [21]. The Council on Ethical and Judicial Affairs of the American Medical Association states that ‘healthcare professionals should relate the benefits of medical student participation to patients and should ensure that they are willing to permit such participation.’ [3]. This educational approach protects both the medical trainee’s psyche and the patient’s right to informed consent. In this study, when subjects were educated on both the training level and associated responsibilities of medical trainees, there was a positive effect on subjects’ reported comfort to be both interviewed and physically examined regardless of the title used. These findings are consonant with the Council’s opinion as well as beneficial for teaching hospitals that are evaluated based on patient satisfaction surveys [22]. Furthermore, research suggests that medical trainees can be integrated into care teams while maintaining patient satisfaction, indicating that education may be all that is required to ensure that patients have a high quality, and ethically informed, encounter [23].

The extent to which characteristics that make one likely to be an online survey taker introduced a significant response bias is a potential limitation to this study. However, research has shown that online samples of this nature are often more representative of the US population than are in-person convenience samples currently utilized in multiple research subfields [13]. Additionally, there is no evidence to suggest that associations between variables found using AMT would differ significantly from those found using other sampling methods. This assertion is grounded in previous work that validated this sampling tool as a high-quality source of data [13, 14].

Additionally, patients in our sample visited the doctor less per year than the national average (2.0 versus 3.9 time per year) [24]. This may be due to the fact that our sample was relatively young (36.3 years of age) and most healthcare is utilized by older individuals, making it possible that this sample does not perfectly capture the population to which medical trainees would be exposed [24, 25]. However, while the sensitivity analysis did not take into account how a healthcare environment may alter patients’ decision-making process, it did reproduce trends when only those who reported using the healthcare system were included in the analysis, suggesting the results may still be generalizable to the healthcare-seeking community.

Finally, it was beyond the scope of this study to explore how race and gender of the medical trainee may impact subjects’ responses. Considering how previous studies suggest certain patient-provider demographic concordances can influence perceptions of quality of healthcare, future studies might explore how demographic concordances impact subjects in the context of medical education [26‐28].

Medical schools claim multiple reasons for introducing early patient-based encounters [29‐34]. As trainees gain increasing access to actual patients, the impact of a lack of standardized titles for trainees must be explored. Poor understanding of medical trainees has the potential to limit patient understanding of the training level of a member of their care team and, thus, potentially limit their ability to provide informed consent. Our data suggest that while no one title connotes a significantly higher level of education or makes a patient feel any more comfortable with the idea of being examined, patients in general are not aware of the responsibilities of the medical trainees on their care team. However, our analysis indicates that educating patients may increase comfort with the idea of being examined, which supports previously posited notions that educating patients better about medical trainees may increase the quality of patient and trainee experience. While this study is not intended to represent the final word on the topic of medical trainee titles or the benefits of patient education, its novel use of a low-cost tool to estimate the impact of these variables on potential patient’s perceptions should be used to inform future research taking place with patient populations and education protocols.