When Health Care is a Privilege and Physician Shadowing is a Right

Musings on the Barbarism of Privatized Health Care

As it is presently constructed, the American health care system is predicated on the pernicious idea that good health care is a privilege. Meanwhile, medical students, residents, and other interlopers regard observing patients’ doctor’s visits to be their right, regardless of whether or not the patient’s consent has been obtained. This dichotomy embodies the egregious inequality inherent in the two-tier system, and is indicative of a complete inversion of the way any humane health care system must be ideologically oriented.

The subject of physician shadowing is inextricably linked with unfettered capitalism and the neoliberal project, where the privileged few have a vast array of options in regards to where and with whom they can seek care, while the under-insured masses can spend countless hours – sometimes in vain – searching for the appropriate specialist that takes their insurance. If an under-insured patient is able to find a specialist that takes their insurance, they often fall prey to the scourge of nonconsensual physician shadowing, as they can be coerced into becoming a medical model and teaching tool without their consent.

Physician shadowing must never be done without the patient’s consent, as this constitutes an egregious violation of medical ethics, patient privacy, and the patient’s moral right to meet with a physician in private should they choose to do so. Moreover, once a patient feels that their trust in the system has been violated, it will be extremely difficult, if not impossible, to ever fully restore it.

While a great deal of lip service is paid to “privacy,” “consent,” and “the doctor–patient relationship” in American teaching hospitals, all of these things are summarily jettisoned once medical students and residents get inculcated with the idea that it is acceptable to shadow a physician regardless of whether or not the patient’s consent has been obtained. In actuality, physician shadowing is a privilege that can be granted by one person, and one person only: the patient.

Under the neoliberal project, many physicians have been pulled inexorably into a vortex of amorality. This is because they are trained in an environment whereby the scourge of free market ideology has distorted their thinking and debased any sense of morality. Indeed, many young physicians are inculcated with the shameful idea that unless a patient has an excellent commercial plan privacy, consent, and confidentiality should have no bearing on the care they will receive.

Medical schools compel undergraduate pre-med majors to shadow a physician for a significant number of hours. This practice should be banned, as these students are not officially medical students. Consequently, they are totally unvetted. Allowing high school students to shadow a physician, or observe medical personnel at work in an emergency room or operating room, is an outrage. Having a secretary serve as a “chaperone” – deemed desirable by some physicians, as this can protect them from lawsuits – is likewise unethical and thoroughly repugnant.

The dismantling of the humanities has played a significant role in fomenting dehumanization and moral bankruptcy in health care, because without the humanities, many health care professionals have lost their ability to be compassionate and empathetic. Indeed, without a humanities education, what separates a urologist from a plumber, or an auto mechanic from a gastroenterologist?

In an online discussion on forums.studentdoctor.net titled “Isn’t Shadowing Intrusive?” doctors and medical students nonchalantly discuss physician shadowing. One philistine writes, “If you agree to the student being in the room, how is your privacy being violated? Everyone should stop being so hysterical – if the patients don’t like something, they can speak up.”

While another defends the right of undergraduates to shadow: “Medical training has to start somewhere. There is not (or shouldn’t be) a glaring divide between premedical and medical education. Better to make sure our students are better prepared for medical school and know what they are getting themselves into. And if anything, many patients are happy to have someone else to talk to. It never was a problem when I shadowed.”

Actually, many patients are interested in talking with a physician in private – and without interlopers barbarically violating their privacy. In all the many times I have experienced this at Weill Cornell and Sloan Kettering, never was my consent first obtained. In fact, at Memorial I had to complain dozens of times before my request to meet with my various doctors in private was finally granted. There are certain departments at Cornell where you can issue complaints ad nauseam, yet they will still not allow a patient with inferior insurance to meet with an attending physician in private.

Another morally bankrupt knave writes: “I’ve seen at least 100 patients in shadowing experiences. Not one asked me to leave. If you’re at a teaching hospital, and the patient has been there before, they know the deal.”

“The deal” is that there is a crisis in American health care, where all too often patient privacy is nonexistent. Also, the notion that patients can easily object is deeply fallacious. Would this hold true with the under-insured, who are acutely aware of how limited their options are? Even a patient with the finest insurance may have a hard time objecting to unwanted observers at Sloan Kettering, as Memorial has a policy of denying patients the right to change from one oncologist to another within whatever department they are ensconced in. Moreover, as these comments demonstrate, the cavalier dismissal on the part of many medical students, residents, and attending physicians that nonconsensual physician shadowing could leave patients with real emotional scars, is indicative of an extraordinary degree of insouciance regarding the delicate nature of the doctor-patient relationship, as well as a deep-seated callousness and moral bankruptcy that has metastasized throughout our entire health care system like a cancer.

Once the callow are inculcated with the idea that nonconsensual physician shadowing is an acceptable and everyday part of learning how to be a doctor, what follows? Catheterizing anesthetized patients without their knowledge? Having medical students do practice pelvic and rectal exams on anesthetized patients? Willful nondisclosure of long-term chemotherapy side effects, such as cognitive difficulties and early menopause? Over-prescribing opioids? Psychiatrists over-prescribing psychotropic drugs? Indeed, these are things that have already come to pass.

It is unequivocally true that the principal devils in the American health care crisis are the private insurance companies, the pharmaceutical industry, and the hospital administrators. Yet throughout my many long and arduous years as a patient, I have witnessed medical students, residents, and fellows instructed by attending physicians to do things that are undeniably unethical. All too often their medical training is corrupted by the two-tier system and the moral bankruptcy that this spawns.

What kind of doctors will medical students and residents become, when every day they are immersed in an environment where do no harm applies to a privileged few? Where the haves are endowed with an endless array of good options, and the have nots are commodified and railroaded into resident clinics which prey on the under-insured, and which coerce patients into surrendering all vestiges of privacy? Privacy, confidentiality, and consent are foundational to any humane health care system, and once they become a privilege for the few, the very basis of medical ethics is torn asunder.

Capitalism has distorted and inverted our sense of morality – so that rights such as good health care, a good education, equality under the law, safe drinking water, affordable housing, etc. – have become privileges, whereas privileges, paradoxically, have become rights.

Once at Cornell Dermatology, I was subjected to an examination with a resident present and a nurse going in and out of the room, despite my requests to meet with a dermatologist in private. As I am at risk for melanoma and was overdue for a checkup, I deemed the visit to be medically necessary. Moreover, had I elected to go somewhere else (a specious argument frequently posited by anti-privacy ideologues), the other dermatology departments in Manhattan that take my insurance are run in a similar fashion. This is not a coincidence, as those who manage resident clinics are acutely aware of the fact that many of the under-insured who walk through their doors have few if any options.

I often think about this resident, and whether she was cognizant of the fact that she played a role in egregiously violating my privacy, as well as the oath that she took to do no harm. Did she fail to see the double standard – that she was participating in an assault on a patient’s privacy that she would vehemently object to – indeed be mortified by, herself? She has since completed her residency at Cornell, and is now ensconced at the dermatology department at The University of Pennsylvania. While these things may look nice on one’s resume, I can’t help but wonder how many hours she had to spend shadowing, and how much of this shadowing was done without the patients’ consent. I can only hope that now that she is an attending physician, she can use her influence to give patients a choice in regards to whether observers are present during their doctor’s visits, and that this will be done regardless of what type of insurance these patients may have. It is regrettable that for many ambitious young doctors privacy and consent matter little in the face of blind obedience, authoritarianism, and careerism.

Doctors know much more today than they’ve ever known before. Yet ironically, they are trusted and respected less than was the case in the 50’s and 60’s. Losing their autonomy to the private insurance companies, as well as being forced to see an increasing number of patients each day, have undoubtedly played a role in the diminishing of the doctor’s prestige. However, a growing number of patients are acutely aware of how morally compromised many doctors have become, as unfettered capitalism and the profit motive have come to permeate and defile the very soul of our society. Indeed, many physicians that ardently defend nonconsensual physician shadowing, are the first to use their superior health insurance plans to avoid this very thing when it is time to see a doctor themselves.

It is deeply disturbing watching medical students and residents being instructed to obey unethical orders from an attending physician. Only with a single-payer system will we disenthrall ourselves from the barbarism of the two-tier system – a system which destroys the souls of doctors and patients alike.

David Penner has taught English and ESL within the City University of New York and at Fordham. His articles have appeared in Counterpunch, Dissident Voice, The Arizona Free Press, and Global Research. He can be reached at: penadam@hotmail.com. Read other articles by David.