When your patient doesn’t want to be treated by a resident

Residents and fellows occupy a special role in the healthcare setting as both trainees and caregivers. It’s incumbent on postgraduate trainees to facilitate both positive treatment outcomes and their own educational goals, while remembering to keep patient concerns at the fore.

Placing patients first may mean deferring care to an attending when the patient refuses to be seen by a resident or fellow—but you shouldn’t let it bring you down or make you question your abilities. 

Making proper introductions

According to the AMA, residents must “interact honestly with patients, including clearly identifying themselves as members of a team that is supervised by the attending physician and clarifying the role they will play in patient care. They should notify the attending physician if a patient refuses care from a resident or fellow.” 

Despite recommendations to introduce themselves as residents or fellows, many trainees don’t take this step. Although research is limited on the topic, a 2008 study delivered intriguing results.^[] The observational study of 100 patient-physician interactions in the ED underscored this lack of transparency.

Although residents identified themselves as a “doctor” 82% of the time, according to the study results, they only shared that they were residents 7% of the time. On the other hand, although attending physicians identified themselves as a “doctor” 64% of the time, they only identified themselves as a supervising physician 6% of the time.

The study also found that physicians were more likely to introduce themselves as a physician when seeing White patients vs Black patients; however, explanations of level of training did not vary based on the patient’s race. Patients had difficulty identifying who was a resident and who was an attending, but they were able to recall the clinician’s level of training 71% of the time when the physician had shared this information. When the physician did not identify their level of training, only 24% of patients could infer this information. Disconcertingly, 60% of patients thought that their resident was the attending, and 27% of patients thought the attending was the resident.

The authors of the study wrote, “Research has shown that improving patient-physician relationships leads to increased compliance and fewer malpractice claims. The discrepancy between the importance patients place on knowing who is treating them and their actual knowledge is a potential source of patient dissatisfaction. This is particularly important because some patients may feel uncomfortable with the idea of receiving care from a doctor-in-training. In fact, half of our patients were either unsure or did not prefer to be treated in a hospital that has physician trainees.”

Importantly, despite this paucity of understanding regarding resident training, 74% of patients still thought it was critical to know the level of training of their physician.

Results of a more recent Canadian cross-sectional study involving 471 patients demonstrated that only 28% of patients were knowledgeable about the role of family medicine residents.^[] Nonetheless, between 54% and 83% reported high confidence in the capability of residents to perform certain routine tasks. Furthermore, 69% of patients agreed to seeing a resident during their next appointment, and those who were highly confident in the residents’ abilities were more likely to do so. There was no correlation between patient level of knowledge and confidence or acceptance.

“Patients visiting university clinics are said to be more comfortable having residents involved in their care than patients attending non-academic clinics. Moreover, patients who have not encountered or worked with medical students much are said to be more likely to refuse the participation of residents in their care,” the authors wrote.

The authors also explained that merely presenting a title to a patient may not be enough for them to grasp the roles and responsibilities of a trainee, and point to “the need to adopt initiatives that provide patients with a clear, succinct and accessible overview of the roles and responsibilities of the different levels of medical learners.”

'Hidden curriculum'

Medical school teaches the ethical principles of patient autonomy, truth-telling, and informed consent as forming the foundation of the patient-physician dynamic, note the authors of the 2008 study. Despite this learning, a resident or fellow may withhold the truth about their level of training due to trepidation that the patient will refuse being seen by a trainee. 

Fears about patients refusing care from residents could be unfounded, according to some research. For instance, in one study, 92% of patients permitted an inexperienced medical student to perform a procedure, while other research demonstrated that patients allow medical students to perform spinal taps. Consequently, being honest about training level with patients may not substantially disrupt the training needs of residents and fellows.

When a patient refuses your care

Although disheartening to the trainee, a patient has the right to refuse care.

“A patient's right to the refusal of care is founded upon one of the basic ethical principles of medicine, autonomy. This principle states that every person has the right to make informed decisions about their healthcare and that healthcare professionals should not impose their own beliefs or decisions upon their patients,” wrote the authors of a StatPearls article.^[]

When a patient refuses care by a trainee, the attending physician must directly address this desire with the patient. The AMA offers the following guidance:

“If after discussion, a patient does not want to participate in training, the physician may exclude residents or fellows from the patient’s care. If appropriate, the physician may transfer the patient’s care to another physician or nonteaching service or another health care facility.” 

Attending physicians walk a fine line between the educational needs of their trainees and the patient’s welfare and dignity. Occasionally, the resolution of educational or patient-care conflicts may require escalation to the ethics committee. 

“All parties involved in such conflicts must continue to regard patient welfare as the first priority. Conflict resolution should not be punitive, but should aim at assisting residents and fellows to complete their training successfully,” writes the AMA.