Saige A Teti
Physician shadowing is the practice of a medical professional allowing a non-medical student observe medical care in the clinic or operating room. Clinical shadowing is distinct from volunteering, and is undertaken by students either planning on pursuing a medical career or considering doing so. Shadowing has become, if not an explicit requirement, important for medical school admission. Shadowing has come under criticism for undermining bioethical principles such as patient autonomy and privacy. Critics argue the practice of shadowing violates the physician’s fiduciary duty to the patient. These criticisms are largely based either theoretical concerns or anecdote. This account reviews the criticisms of shadowing and assesses the claims, concluding: 1) The theoretical concerns are not borne out in practice, and 2) anecdotal stories of poor shadowing practices should not undermine shadowing in general any more than poorly-practiced medicine should undermine medicine in general.
Clinical shadowing occurs when a medical professional agrees to allow a non-medical student to observe the provision of medical care to patients.  Clinical shadowing is distinct from volunteering, in which a volunteer assists with some non-clinical aspect of health care delivery. Shadowing is undertaken by those who plan on studying medicine in the future and wish to know more about the practice of medicine; undergraduate premedical students have little exposure to clinical practice before applying to medical school, and therefore very little understanding of what practicing medicine is like. [2,3] While clinical shadowing reduces the risk of incurring huge debt without real knowledge of the profession, there are other benefits to clinical shadowing–to the shadow, [4,5] patient,  the physician, [6,7] and society at large. [1,8] However, the practice is controversial. [3,5,9] Some claim clinical shadowing is unethical. The following analysis will address the ethical aspects of the practice.
One critic of clinical shadowing, Elizabeth Kitsis, raises four potential ethical issues in “Shining a Light on Shadowing.”  The following are the principal claims that she and other opponents of clinical shadowing raise:
- Potential violations of the physician’s fiduciary duty
- Maintenance of privacy and confidentiality
- Coercion of patients
- Misrepresentation of the shadow
Opposing this, others argue the potential issues associated with shadowing are abstractions from reality, serving only to prevent those who aspire to a career in medicine from gaining meaningful knowledge and experience that is otherwise unattainable. [11,12] This is especially true for students who do not know someone working in the medical field  and those from underrepresented groups. [14,15] Opponents of clinical shadowing allow an exception for medical students in that they consider the medical student’s commitment to medicine to have reached the threshold justifying involvement in clinical encounters. 
I spent the past three summers shadowing: a pediatric general surgeon in clinic and the operating room, a nurse practitioner in a pediatric neurology clinic, and a pediatric neurosurgeon in clinic and the operating room at two pediatric hospitals. I feel compelled to respond to the arguments of clinical shadowing opponents. At the time I began shadowing, I was neither a medical student nor a college student; I was going into my senior year of high school. Based on my experiences, discussions with other shadows, and research into the matter, I find many of the arguments against shadowing problematic; they are hypotheses with no data to support them , and unconvincing in light of actual practice. Dr. Kitsis presents the most thorough arguments against the practice, so her formulation of the issues will be considered here, however the points raised represent generally the opposition to shadowing.
One may argue clinical shadowing risks a breach of the physician’s fiduciary duty to the patient.  The fiduciary duty requires the physician put the patients’ interests first, above all other interests. [16,17,18] The critic may question whether or not the physician’s fiduciary duty is violated by having a shadow present; one may ask how the patient benefits from having a student present during an appointment or in the operating room.  However, the patients’ interests coming first does not necessitate the elimination of all other interests, but rather that “a physician shall, while caring for a patient, regard responsibility to the patient as paramount.”  Second, the fiduciary duty does not require that everything benefit the patient, just that the patient not be harmed due to other interests.  Third, the fiduciary duty serves to ensure patients know they will not be harmed by a doctor’s pursuit of other interests at their expense.
In my own experience, and that of others, [15,19] the physician introduces the clinical shadow and asks the parent and/or patient if they are comfortable with the shadow being present. Many times, the parent, the patient, or both would ask me questions–where I go to school, how old I am, and my interest in medicine. There was never any sense that the patient’s interests were not put first; as long as the patient feels free to decline to allow the shadow to be present, the physician’s fiduciary duty remains intact. Evidence presented by Bing-You, Hayes, and Skolfield (2014) has shown:
78.1% of patients felt college students had a neutral effect on their visit and denied having concerns about confidentiality (87.5%). No patient felt that having the college student present affected their ability to maintain a trusting relationship with their physician. 
Despite concerns raised by other authors about the possible negative effects of physician shadowing by college students, this study shows that patients feel the impact to be primarily neutral and that there are many perceived benefits to both student and patient. 
This evidence suggests the presence of a student in a clinical encounter does not have the detrimental effects critics claim are likely. Instead, the presence of a student appears to have no negative effects on the physician–patient relationship. Moreover, a Kitsis and colleagues’ review article on physician shadowing (2015), reported no evidence of violations of the fiduciary duty in the context of shadowing among the 13 articles reviewed. [3,20]
The second argument raised is that clinical shadowing may violate patient confidentiality and/or privacy; having a student present during physician-patient conversations may result in disclosure of protected health information, or make the patient feel uncomfortable about sharing it.  Let us consider the argument that shadows pose a risk to patient confidentiality. Medical students, residents, and fellows are assumed to maintain patient confidentiality, and the basis of this assumption has two parts. First, the reasons for patient confidentiality have been explained and understood. Second, HIPAA forms have been read and signed, confirming the understanding of their meaning and purpose. The process of becoming a clinical shadow typically includes this same training. [14,21] There were three steps that served to educate me about HIPAA’s importance and the purpose it serves. First, I had to read and sign detailed HIPAA documentation. Second, I had to read and sign a summary of key HIPAA privacy points. Third, I was required to complete a test on HIPAA privacy and other hospital policies.
The process I went through is precisely the procedure Teitz and Wong and Gold suggest, [12,22] and that critics agree would help protect patient privacy and confidentiality.  It is difficult to see any difference in practice between a medical student, an intern, or a shadow as regards confidentiality; all go through essentially the same hospital process to ensure the patient’s rights to privacy are respected. Some contend shadows are not sensitive to the doctor-patient relationship like a medical student would be. However, a study of the Stanford Immersion in Medicine Series (SIMS), a shadowing program offered since 2007, reported a as a primary outcome, “significant increases in familiarity with physician responsibilities and in understanding physician-patient interactions.”  Protecting privacy is a case-by-case determination made by first, by the physician using their judgment about the nature of the particular patient and clinical encounter which is then either approved, or not, by the patient.
The third argument put forth against clinical shadowing is that a student’s presence may also make a patient feel as if they cannot ask the student to leave without offending the physician, and is thus possibly a subtle form of coercion. However, this argument assumes the patient or parent believes the physician has an investment in the shadow’s presence in the room; in reality, neither the physician nor the shadow will be offended, because both understand that the patient’s comfort comes first. Any investment the physician might have in the shadow in undoubtedly lesser than the investment they have in being a good physician and making the patient feel comfortable.
This argument also ignores the relationship between the physician and the patient or parent. In all of my experiences, and those reported by others who have shadowed a physician,  the physician or nurse practitioner clearly established the parameters of the clinical encounter, including prioritizing the wishes of the patent or parent regarding their comfort; making the patient and/or family feel at ease, able to voice their concerns, is central to all clinical encounters.  This is the standard in the era of patient-centered and family-centered care. 
The fourth and final argument put forward against physician shadowing by students is that:
An individual must have a legitimate role to justify being present during a patient-physician encounter; otherwise that presence can be considered voyeuristic. 
This argument is circular: this is a restatement of the proposition that ‘only those who have a “legitimate” role are justified to be present in the exam room.’ However, that is exactly the point the author is trying to prove. Second, the proposition that a doctor would lie about the shadow’s identity is an uncharitable view of the physician and of the shadow. The patient-physician relationship is based on trust, and no physician abiding by professional codes of conduct would jeopardize that relationship with any patient merely to get a shadow in the exam room. [19,27] Moreover, multiple studies have found patients are very positive about medical student shadowing, frequently for altruistic reasons. 
To address the issue of “legitimacy,” and who has a legitimate reason to be in an exam or operating room, critics sometimes make a distinction between medical students and other students. Two claims are made. First, that medical student shadowing “may ultimately benefit society by providing a valuable educational experience that produces more humane, competent physicians.”  Second, medical students have committed themselves to medicine, which college students, and certainly high school students, have not. The critics essential point is the purpose of shadowing for medical students is to teach them medicine, whereas the purpose of shadowing for college students is to “help them choose a career and gain admission to medical school.” 
It is true that high school and college have not made the time and financial commitment to medicine that medical students have. However, in order to become a shadow one must find a physician who is willing to take on a shadow, seek out the various administrative requirements, usually involving multiple hospital departments, ensure one’s required immunizations and tests and tests are up to date, be cleared medically, read thoroughly and sign HIPAA forms, and take a safety test—before stepping foot in an exam or operating room. This process took me 3 months to complete. This is not the same commitment a medical student makes, but clearly those who shadow are committed, considering the time and effort required to become one. OR shadowing, for example, requires the student to be at the hospital for morning surgical rounds.
Both multiple studies and individual accounts suggest that time is well spent by students who make the effort to engage in pre-medical school healthcare experiences. [19,20,28] One study involving the mentoring of undergraduates by hospitalists that included shadowing experiences found 95% remained committed to careers in healthcare in a two-year follow-up. 
The arguments against shadowing seem to be supported by personal opinion rather than evidence or experience. This has had an unfortunate effect on policy: AMA Resolution 310-A-13, a Report of the Council on Medical Education Guidelines for Students Shadowing Physicians, quotes Kitsis in stating, “any potential benefits of shadowing from the student perspective “are eclipsed by potential damage to the patient-physician relationship.”  In a follow-up to “Shining a light on Shadowing,” the authors end their discussion section with the following claim:
…significant ethical issues related to shadowing have been identified, including maintaining patient trust, ensuring patient privacy, avoiding undue influence in securing the patient’s agreement to participate, and avoiding misrepresentation of the student’s role in a physician–patient encounter.6 These ethical concerns are more applicable to shadowing programs for high school and college students, who have not yet entered the medical profession or received professionalism training than to programs for medical students and medical school graduates. 
However, the citation for that claim (footnote 6) is, in fact, the lead author’s own article, “Shining a Light on Shadowing,”  which contains no evidence supporting these claims. The follow-up article, “Physician Shadowing: A Review of the Literature and Proposal for Guidelines,” reiterates these “ethical concerns” without citing any actual evidence. 
More is involved here than just student interests. In the mandated annual Association of American Medical Colleges graduation questionnaire, 40% of graduating medical students state, “their mentors and role models had a strong influence on their career choice.”  Other studies point to the importance of early engagement with students.  This is not just a matter of concern for would-be shadows. Following a decline in interest in surgery as a profession,  research found many students make career choices before starting medical school, and the majority of medical students choose a specialty before starting clerkship rotations. [33,34] This means many students had made career choices before being exposed to surgery or surgeons. The increasingly abbreviated clerkships further limit interaction with attending surgeons. [35,36] As one group of surgeons wrote on the subject:
It is up to us, the surgeons, the faces of surgery, to give students this experience… Surgeons must get involved early in the lives of medical students before clerkship rotation and perhaps before they begin medical school. 
Those surgeons developed a mentoring program with the hypothesis that scholarly skills could be learned by novice students, and those skills would help them achieve long-range professional goals.  The Blue Ribbon Committee on Surgical Education studied the 20% attrition rate of general surgery residents and found a need for greater emphasis on early skill-building and mentorship.  Research on attrition has shown that many residents indicate a lack of role models as a main reason for leaving the profession.  Additional efforts have been made to attract women to the still overwhelmingly male profession. 
This isn’t true only of surgery; a hospitalist organized mentoring program for undergraduates had similar motivations and similar results,  as did a Drexel University College of Medicine program for high school students.  Following the Carnegie Institute report, “Educating Physicians” calling for greater focus on assisting student trainees in forming their professional identities and behavior, a Cornell study showed that process could begin prior to medical school.  Rounding out those findings, a review article concluded that early clinical experience and clinical shadowing increased preparedness of those transitioning from medical student to junior doctor,  which can only be of benefit to patients.
The basis of clinical shadowing is observation and learning.  The issues of potential violations of the fiduciary duty, the maintenance of privacy and confidentiality, coercion of patients, and misrepresentation of the shadow have been shown to be unsupported by evidence and contrary to the actual experiences presented here.  By the critic’s reasoning, all those who aren’t already medical students would be disallowed important experiences that have been repeatedly shown to be beneficial, for reasons those critics have failed repeatedly to demonstrate. [10,20]
Perhaps most significantly, physicians encouraging clinical shadowing could democratize early access to the motivations for, and study of, medicine. While both Kitsis and I have family members who facilitated our access to the medical world, many underprivileged persons lacking these connections are blocked from exposure to such pursuits at a formative time in the development of their future interests.  as well as those from underrepresented groups. [14,15] This includes women in surgery.  For these reasons, shadowing should be broadly encouraged, along with adhering to the good professional practices that ensure patient protections.
The authors have disclosed no conflicts of interest.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Saige Teti is a pre-med student double majoring in chemistry and philosophy at St. Mary’s College of Maryland.
Saige A Teti
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