After introducing myself as a first-year medical student working with the attending physician, I went through the medical history with the patient to ascertain his chief complaint and the history of present illness. Since this was only a six-month follow-up appointment in an internal medicine outpatient clinic, there was not much to cover besides checking whether his medications were up-to-date and how he had been managing his chronic conditions. As this was my last patient of the day, I asked if I could practice various aspects of the physical exam that were not necessary for his appointment. Typical of my experience in longitudinal clinic, the patient obliged and thought it was great that he would get some “additional care.”
“Are you a fellow or something?” he asked during the exam.
“No, no. I’m a first-year medical student,” I reminded him.
It seems that “fellow” and “medical student” were synonymous to this individual.
Part of the curriculum of my medical school includes various readings in both the social sciences and the humanities. We recently reflected upon the titles we are known by, such as medical student, student physician or student doctor. More specifically, what is meant by the names and titles we are known by? After contemplating how to introduce myself to patients, I offer the following reflection.
Renowned sociologist Erving Goffman popularized the notion that “the self” is a performance based on a culturally-constructed script. This script, according to Goffman, is composed of “performers and audiences; of routines and parts; or performances coming off or falling flat; of cues, stage settings and backstage; of dramaturgical needs, dramaturgical skills, and dramaturgical strategies.” The medical student and patient encounter is a performative moment in which both the student and the patient play dual roles as performers and audience members. This idea of performance is further complicated by Chicago sociologist Robert Ezra Park’s comments in “Race and Culture“: “It is probably no mere historical accident that the word person, in its first meaning, is a mask. It is rather a recognition of the fact that everyone is always and everywhere, more or less consciously, playing a role.”
The idea that the medical student is playing a role influences how I introduce myself to patients in longitudinal clinic. Before attending medical school, I assumed various titles, including college student, graduate student, seminarian, theology student, pre-med, anthropology student, biology student and social scientist. I use these titles, or script identifiers, to answer questions like “what do you do?” or “what do you study?” Stated another way, I use “script” terms that are easily identifiable to others within my culture despite the fact that these terms have little existential significance for me. Rather than providing a long monologue on who I am and what I study, I wear a mask and put on a show in order to engage in quick and effective communication. When I am taking a medical history and going through the physical exam, I am at once a performer of the art of medicine for the patient, as well as an audience member to the performance and narration of the patient’s illness (Kleinman 1988).
So, how do I introduce myself to patients in clinic? I have chosen to identify myself as “a medical student working with [the attending physician].” In our society, patients are more likely to know what “medical student” means compared to “student physician” or “student doctor.” However, my longitudinal clinic experience seems to indicate that patients are often unaware of what is meant by the term “medical student.” Thus, one should proceed with great caution when determining how to identify him or herself to a patient.
Marracino and Orr (1998) state that “the patient could expect a responsible learner who performs what he is trained to do under the direct and constant direction of a licensed doctor. This approach is in accord with moral and legal principles — a solution that fulfills ethical duties to the patient and provides an optimal environment for learning.” If the goal of medicine is to learn how to heal and cure patients, as well as accompany them on their journeys of illness and flourishing, then establishing an honest relationship with the patient is of utmost importance.
A critical analysis of the ethics of medical student performance and its role in obtaining an illness narrative from the patient has yet to be written. Will a medical student receive different information from the patient depending on the name she uses to introduce herself? Is a patient more likely to divulge the details of her illness if she thinks the student in front of her is a fellow as opposed to a medical student? Is the goal of medicine solely to ascertain the health concerns of the patient in order to implement a plan to address these concerns, like a technician? I push back and ask: should not the way information is obtained, specifically in the context of the patient’s perception of the performer in front of her, be considered carefully in order to avoid the dangers of medical paternalism?
At the end of the day and ethical considerations aside, medical student, student physician and student doctor “can mean almost anything, and therefore mean very little. There is no clear role implied by the names students use at the time of introduction” (Marracino and Orr 1998). I use the term “medical student” in clinic for pragmatic reasons, namely, to use a term the patient will hopefully understand specifically in the context of my lack of licensure and curing capabilities. After establishing this basic element of honesty and trust, the most meaningful part of the entire process occurs when I begin to dialogue with the patient, at eye level, leaning slightly forward, completely focused on her illness narrative. The name I use is not important to me, but it might be important to the patient. Who the patient perceives I am will affect how they allow me to accompany them. The experience of accompanying individuals is what I, and probably they, find to be most meaningful.
How have you chosen to identify yourself to patients?
Contributing Writer
Cleveland Clinic Lerner College of Medicine
Joshua Niforatos is a medical student at Cleveland Clinic Lerner College of Medicine. Born and raised in the suburbs of Chicago, he eventually made his way to University of New Mexico (UNM) where he earned bachelor degrees in both cultural anthropology and biology. He then went on to earn a Master of Theological Studies at Boston University School of Theology where he studied theology, anthropology, and ritual.