The Ethics of Shadowing And Practicing Medicine

Posted By: Paul   |   Shadowing   |   10 Comments

ethical practice

You don’t need to be a licensed PA to begin practicing ethically.

I recently received a letter from a woman (I will call her Joan) who found Inside PA Training while researching the ethics of shadowing.  Her letter brought forth all kinds of feelings for me, and I think it’s a great way to discuss ethical practice in medicine.

Dear Paul,

I recently had an appointment with an orthopedic doctor for knee issues. After I had my vitals checked and was wearing paper “shorts,” the PA came in and introduced herself and the very young lady with her as her assistant.  I had to ask what this “assistant” had to do with my care and it was only then that the truth came out.  She did not ask me if I was okay with a shadowing student in the room.


Joan requested the student to leave.  She told me that she had already been a patient in a similar situation once before.  She felt that these episodes demonstrated a lack of professional conduct and common courtesy, and that they ruined the sense of trust that she had with her provider.

I hope that in your shadowing you will be prepared for such a situation and take the ethical position.  As a medical professional, you will, on a daily basis, be trusted by your patients to protect their interests, including their privacy.

No matter your role, I hope that in all your interactions with patients you will treat that trust as a gift and not misuse it.

The worst part about this story (to me) was not that the shadowing student represented herself as an “assistant.”  It was that any licensed provider — in this case a physician assistant — would misrepresent someone else who has no training and no official capacity as anything other than what they really are.  Obviously the provider felt that if she was vague enough, the fact would be glossed over and the patient would get what they wanted while the student did too.  Unfortunately, things didn’t work out that way.

Again and again research on the ethics of healthcare has shown that the earlier students are introduced to practicing ethically, the more ethically they are likely to practice.  It starts with supervisors setting good examples.  But alas, if you study medicine you will sometimes have a bad role model, so…

If you are asked to do something that you are uncomfortable with or that you believe is unethical, be ready to say “I’m not comfortable with that.” These words may displease the person who told you to do it.  Say them anyway.

At this point you may be saying “Duh.  I would definitely tell them I can’t do it.”

But it’s harder than it sounds. Have you heard of the Milgram experiments?  They are some of the most famous experiments in psychology.  Stanley Milgram was a social psychologist whose research in the 1960’s demonstrated that the majority of people will hurt and/or endanger someone they do not know because someone else with authority — someone wearing a white coat — told them to.  In an ironic twist of fate, though famous, Milgram’s experiment is now considered unethical itself because his subjects were potentially scarred by the revelation that they would hurt others so easily.  Click here to watch video on these fascinating experiments.

There are all kinds of ethical problems that come up when you examine stories like Joan’s.  She mentioned was how she wasn’t given a choice to have the student present or not.  This is violation of the ethical rule of patient autonomy.  Can you identify any that I’ve left out?

What you can learn from a licensed professional’s mistake

(Before you even start your training)

  1. Respect your patient’s right privacy
  2. Be honest with patients at all times
  3. Be willing to say (politely) “I don’t feel comfortable doing that.”
  4. Involve your patients in the decisions that affect their care whenever possible.
  5. Finally, be open to learning from your patients.*

*Dear Joan,

I’m sorry that you had such an experience.  On behalf of the PAs of the world (if I may be so bold), I apologize.  Thank you for taking the time to share your story — I’m sure it will improve our work with patients.    -PK


  1. Cheers May 1, 2014 at 11:09 am - Reply

    Man! There’s no room for providers ignoring or, in Joan’s case, attempting to flatly overrule patients’ rights with vagueness or misrepresentation. Interactions like these testify to the provider’s priorities: billing another visit or helping a patient take an active role in her own healthcare.

    Thanks, Paul, for a great reminder.

  2. Brian Wallace May 5, 2014 at 7:31 am - Reply

    We take a lot of things for granted as we go through our daily routines. I’m sure this was simply an easeir way for the PA to get through her day. Out of 10 times how often do I correct a patient that says “thanks doc”? I don’t know, maybe 7 or 8 times. Certainly I don’t correct them 10 out of 10 times. I know it’s a little different, but it is common to sacrafice trust in an effort to speed through our days. This is something to be avoided not just with patients, but with family and friends as well. Once trust begins to erode even in the smallest ways, it is very difficult to recultivate.

    • Paul May 5, 2014 at 7:28 pm - Reply

      I know exactly what you mean. And I have patient’s who tell me, “I know, I know – you’re a PA. But as far as I’m concerned, you will always be Dr. Paul to me.”

      • Brian May 6, 2014 at 2:29 am - Reply

        And then is it the right thing to correct them when really they are trying to show you respect because just calling you Paul feels awkward?

        Bottom line. Tell the truth. Keep your patients informed. Tell them when you don’t know something. Tell them when a problem they are having is hard for you solve. They will trust you more.

  3. joanna July 19, 2014 at 2:22 pm - Reply

    when I shadowed a family practice PA she introduced me as a student and asked if it was alright if I observed, and while I WAS a student, I was not a PA student, though who knows what the patient thought. BUT she did ask if it was ok if I observed, and besides before you shadow you’re supposed to sign and read HIPAA, etc, like any other employee with access to patient records, you aren’t just supposed to show up one day and shadow them

    • Paul July 27, 2014 at 9:19 am - Reply

      Good point. I think what you’re supervising PA did was probably okay. I definitely hope if she had been asked what kind of a student you are she would have been very honest about it. Any provider will tell you that if you tell a patient what to expect, as long as you tell them with confidence, the patient will generally follow your lead and go with it. So most providers introduce students and say “Oh this person is a student,” like it’s no big deal.

  4. gibson February 11, 2015 at 11:13 pm - Reply

    I’m sorry maybe i missed something but why would “joan” get upset about the PA bringing in an extra body to learn? Each generation is the new face of medicine so I’m a little confused as to where the distrust lies.
    -I hope to become a PA one day

    • Paul February 28, 2015 at 8:51 pm - Reply

      Joan was bothered (rightly, I think) that she was asked if someone could come in who wasn’t a PA student. They implied that the shadowing person was a PA student, but they were an undergrad student. It was deceptive. Ethically, the patient has the right to choose who is a part of their care, and to do that properly, they need ALL the information.

  5. Madison March 26, 2015 at 9:21 pm - Reply

    Do you have any suggestions about how to head off this type of situation? What I mean is: is there some way to make sure the practitioner you are shadowing won’t put you in this situation, without implying to them that you think they would? It seems like once the practitioner introduces you as their “assistant” or something similar, ethically, you would be obligated to make sure the patient understands that this is not the case, but professionally, once that blunder is made, you would potentially cause more problems by correcting it to the patient. I am in my undergrad right now and do not know the PAs in my area so I will be shadowing strangers essentially, and I’d rather avoid that situation if possible (as I do believe in the patients right to leave someone unqualified, such as myself, out of their care, if they so choose).

    • Paul April 5, 2015 at 4:44 pm - Reply

      YES – IT’S SIMPLE: when you enter the room, tell the patient, YOURSELF, and tell them exactly whom you are. I do this every time I meet a patient for the first time.

      “Are you John?”
      “Well, then I’m in the right room. Nice to meet you. I’m Paul, and I’m one of the physician assistants here.”

      It’s worked very well for me, and I’ve never had a patient not get that I’m a physician assistant. I do get plenty of patients who choose to call me Dr. Paul, even after I correct them.

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