Q: A patient’s daughter, a high school senior, had accompanied her mother for her semi-annual eye examination. The daughter was very attentive to what I was doing and told me that she would soon be starting a pre-med program in college. She thought that ophthalmology was fascinating and wanted to practice it eventually. She asked if she could shadow at my practice during her mid-term vacation. I recall that such activities were common and helpful for students when I was that age, and I would like to do this, but we live in a much more regulated world now. How would I set this up?
A: You can do it, but you do have to follow some rules. Let’s start with patient confidentiality.
The HIPAA Privacy Rule exception to the need for an authorization to share patient health information for “healthcare operations” includes “conducting training programs in which students, trainees, or practitioners in areas of healthcare learn under supervision to practice or improve their skills as healthcare providers.” That is why, for example, there can be bedside rounds. Covered entities are, however, still expected to shape their policies and procedures so that only the minimum necessary uses and disclosures are made in these settings, since they remain without direct patient consent.
But does this apply to you? She is a student, but not a medical student yet, and this would be an informal arrangement in a private office, not an adjunct training program with her school, and precepting underpins patient care while a “shadower” is there solely for their own benefit in deciding about a future career.
Therefore, rather than trying to parse this into an exception to a law that unequivocally favors patient privacy, you should tell the patient whose care she may be shadowing that a student who is considering a career in medicine is observing in the office that day and then ask them if they agree to that student sitting in on their appointment. It is essential to do this while she is not in the room so that the patient does not feel pressured to agree.
She should also be instructed—in writing and then signed by her to instill the gravity of the issue—that although the patient agreed to let her observe, she is not permitting to share information further. Emphasize that nothing of what she sees or hears can leave the office, especially over social media. If she plans to do a class presentation on her experience, you should review it to ensure that it is fully de-identified.
You should also consider liability issues. Your malpractice carrier insures you as a private practice with no teaching role. If a problem arises during a case that she is shadowing, you should ensure that your insurer cannot disavow coverage. If you do not inform your carrier in advance that you may be working under a potentially distracting circumstance, they may not agree to provide coverage. So, inform your insurer in writing that a student will be present but only with patient consent and only as an observer and get their agreement that this is acceptable.
Finally, you should consider how you will handle appointments, since your patients, unlike those in a hospital, do not expect to be teaching subjects. Even patients who do may be unnerved by what they hear during a teaching session.
You should review the case with her before the appointment, and then treat the patient as you normally would. Provide only general explanations to the student about what you are doing or what you are inviting her to look at, and then review the case with the student after the patient has left. In other words, do not discuss pathology with the patient present. This is not a mandated privacy issue, but a matter of respecting the patient’s emotional comfort.
Once those issues are in line, enjoy bringing along the next generation of your profession.
