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Physician Shadowing

A Review of the Literature and Proposal for Guidelines

Kitsis, Elizabeth A. MD, MBE; Goldsammler, Michelle MD, MS

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doi: 10.1097/ACM.0b013e318277d5b2
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Abstract

Physician shadowing is a process wherein a student or a trainee observes a physician conducting his or her daily work. Also known as a “structured observership”1 or an “observational experience,”2 shadowing is a common activity among students contemplating careers in medicine. At one liberal arts college, 80.2% of premedical students responding to a survey reported having had some experience with shadowing.3 Why has physician shadowing by college students become so widespread?

First, shadowing may help students develop realistic perceptions of medicine as a career. Over the past several decades, there have been dramatic changes in the practice of medicine, resulting from economic pressures and shifts in societal expectations. Compared with physicians practicing 50 years ago, physicians today have less autonomy, higher workloads, less time with patients, more bureaucracy, and lower compensation.4 Many currently practicing physicians entered medicine during this transition period and may not have anticipated such changes. These career challenges may contribute to the burnout that 30% to 40% of physicians in the United States experience.5 One approach to minimizing burnout among future physicians may be to ensure that students gain awareness of what medical practice entails through mechanisms such as physician shadowing.

Second, medical school admissions committees commonly ask applicants about their clinical experiences, including shadowing, as a way to identify motivated individuals who have realistic expectations.6 Some premedical students participate in formal shadowing programs offered by their colleges and universities; others set up informal arrangements to observe physicians in the community.

It is important, however, to reflect on ethical issues related to physician shadowing by college students.6 Given that 43,919 students applied to U.S. medical schools in 2011–20127 and approximately 80% of them likely shadowed physicians,3 we estimate that 35,135 patients participated in at least one shadowing experience involving these applicants. This means that a college student sat in on an encounter between these patients and their physicians. Exposing such large numbers of patients to shadowing warrants further exploration of shadowing’s value to students and its potential impact on the physician–patient relationship. Establishing guidelines that could help participating students and physicians avoid ethical problems should also be considered.

Accordingly, we reviewed the literature to explore the process of physician shadowing, its goals, and its effectiveness. Our research questions were: (1) Does shadowing help premedical students gain an understanding of what is entailed in a career in medicine, in a consistent and effective manner? (2) Are there ethical problems associated with physician shadowing by premedical students? and (3) For what other reasons do individuals shadow physicians? On the basis of our findings, we offer recommendations for developing guidelines to address practical and ethical issues and propose a code of conduct.

Method

We searched the MEDLINE database via Ovid for English-language articles published from 1948 through week 1 of March 2011, using the medical subject headings physicians (exp [exploded]), students (exp), and ethics (exp) in combination with the terms volunteer*, shadow*, observer*, apprentice*, mentor*, applicant*, and career*. Articles eligible for inclusion described physician shadowing programs and/or assessed the value of physician shadowing independently or in comparison with other educational methods. We did not place limits on participant type or study design. We excluded editorials, letters to the editor, commentaries, perspectives, literature reviews, and duplicate reports. We supplemented our database search by manually reviewing the references of the articles that met inclusion criteria to identify other potentially relevant publications.

Our search strategy, which was intentionally broad in order to capture all relevant publications, identified a large number of articles that used different definitions of our search terms (e.g., searching shadow* also found articles about radiology). We screened the titles and abstracts of all publications for articles that included information on physician shadowing: One of us (M.G.) screened two-thirds of the search results, whereas the other (E.K.) screened one-third. If one of us questioned whether an article was relevant on the basis of its abstract or title, we discussed it. If we could not reach agreement, we analyzed the full text of the article.

We retrieved the full text of the articles we identified as related to physician shadowing; each author read the articles whose titles/abstracts she had screened to determine whether these articles met our eligibility criteria. We both read all articles selected for inclusion and, using a tool we developed, independently extracted data about program goals, characteristics, requirements, and evaluations. We then compared our results, and when they were discrepant, we referred back to the original articles to reach agreement.

Results

Our MEDLINE search and manual search identified 770 unique publications, whose titles and abstracts we screened for relevance to the research questions. We reviewed the full text of the 73 articles (9%) related to physician shadowing against all eligibility criteria, resulting in a final set of 13 (2%) articles for analysis (Figure 1).1–3,8–17 All 13 studies were published after 2002; 11 were published after 2005. Table 1 details shadowing program characteristics for each of the 13 articles. Table 2 provides information concerning shadowing program goals and study evaluation data.

T1-31
Table 2:
Goals and Study Outcomes Reported in 13 Articles Included in a Review of the Literature (1948 to March 2011, week 1) on Physician Shadowing
T2-31
Table 1:
Characteristics of Physician Shadowing Programs Described in 13 Articles Included in a Review of the Literature (1948 to March 2011, week 1)
F1-31
Figure 1:
Literature search and selection process for articles published from 1948 to March 2011, week 1, describing and/or assessing physician shadowing programs. *The total number of excluded articles is greater than 60 because 13 articles were excluded for more than one reason.

Characteristics of shadowing programs

Four studies were conducted in the United States, seven in the United Kingdom, one in Australia, and one in Canada. Participants included students in high school, college, or medical school, as well as recent UK medical school graduates preparing to start their clinical work as preregistration house officers (pre-PRHOs) and international medical graduates (IMGs) beginning their careers in a country different from the one where they had earned their medical degrees.

Two articles described programs that involved shadowing only.1,2 The other 11 publications described programs that combined shadowing with additional educational interventions, such as mentoring, lectures, clinical conferences, and clinical skills sessions.

Most programs were hospital based; participants shadowed physicians as they saw inpatients or treated patients in the emergency room. The two high school programs also provided outpatient encounters.9,10 The timing and duration of shadowing programs varied. The number of participants in individual programs ranged from 9 to 102.

Applications were required for admission to the high school programs.9,10 Interviews were required by one college program11 and the IMG program.12 The other publications did not describe application processes.

Although none of the articles detailed programs’ training requirements, one described a code of conduct for participating medical students. That program’s code was posted on its Web site and included a commitment to “respect a patient’s confidentiality, privacy and right to refuse to be seen.”1

Program goals

In both programs for high school students9,10 and in one program for college students,11 shadowing was viewed as a means to interest students in the field of medicine. One of the high school programs was designed specifically to recruit U.S. students for practice in rural areas,10 whereas the other targeted UK students from lower socioeconomic classes and exposed them to a variety of specialties.9 The college program sought to create enthusiasm among students about medicine in general, and academic surgery in particular, by exposing them to practicing surgeons who were highly engaged in their work.11 In addition, two articles described studies that attempted to determine whether medical students’ shadowing of emergency medicine physicians attracted students to the specialty.1,2

Shadowing programs for pre-PRHOs in the United Kingdom were based on the General Medical Council’s recommendation in Tomorrow’s Doctors (2003) that new medical graduates “should have opportunities to shadow the PRHO in the post that they will take up when they graduate” to ensure that they are “properly prepared for their first day as a PRHO.”18 These programs8,13–17 focused on easing the transition from medical school to residency by providing graduating students with opportunities to become familiar with their new working environments and colleagues, as well as to improve their confidence and proficiency in clinical skills.

Finally, the Observer Program in Australia was designed to integrate medical graduates from other countries into the Australian health care system.12

Program evaluations

Seven studies reported quantitative data only; six of these studies collected data via surveys,1,2,9,11,14,17 whereas one collected survey data as well as objective data measuring clinical skills.15 Three studies reported qualitative data only, which was gathered via focus groups and/or interviews.8,12,13 Three studies provided both quantitative and qualitative data.3,10,16 Data were not reported in detail in any of the articles.

As noted above, only two articles described programs in which shadowing was the sole intervention.1,2 In three of the seven studies in which respondents were asked to select the most important program component, respondents identified shadowing as the most important activity.10,16,17

Among the studies of high school9,10 and college11 programs that measured students’ changes in interest in the field of medicine after participating in shadowing, two demonstrated an increased interest,9,11 whereas the third reported no significant change.10

Physician shadowing by medical students in both of the emergency medicine studies1,2 affected participants’ interest in pursuing that specialty. A large majority (84%) of respondents in one study indicated that they would pursue additional emergency medicine opportunities.1 In the other study, about one-quarter (24%) of respondents reported developing more interest in emergency medicine, whereas approximately one-quarter (29%) lost interest; almost half (46%) experienced no change.2

A UK study reporting on a national survey of PRHOs found that a higher proportion of respondents who had shadowed as pre-PHROs indicated that they felt well prepared for their new position compared with those who had not shadowed (58.6% versus 48.5%, respectively).14 In another UK study—the only one in this review that included objective outcome measures—researchers measured pre-PRHOs’ competence in basic clinical skills before and after their shadowing experiences.15 The study authors detected an improvement in participants’ clinical skills (e.g., blood pressure, venipuncture) following a one-month shadowing period.

Shadowing participants who provided feedback in interviews and focus groups generally described positive reactions to the experience. For example, pre-PRHOs attributed an increase in their confidence to the opportunities provided by the shadowing program to meet team members and patients and become familiar with the new facility and its procedures before they started working.13,16 IMGs who participated in the Australian program viewed shadowing as highly valuable.12 They felt that it improved their confidence and competence and provided them with a good understanding of the Australian health care system.

Some individuals criticized aspects of their shadowing programs, however. Students who participated in the High School Rural Scholars program noted that their preceptors were not always clear about the students’ role in the clinical environment, which led to a lack of consistency in their experiences.10 In addition, some students felt that this program dedicated too much time to preparation for the ACT college entrance exam.

Pre-PRHOs and IMGs similarly reported a lack of consistency among or within their programs, resulting in variable experiences.12,16 Pre-PRHO respondents in two studies suggested that pre-PRHOs should assume more clinical responsibility toward the latter part of their shadowing experiences to expedite their transition to practice.16,17 Of note, another pre-PRHO program had already incorporated a “work-based clinical apprenticeship” into its shadowing program.13 Some IMGs also expressed concerns about lack of compensation and difficulties in relationships with specific supervising physicians.12

Discussion

Physician shadowing is a common practice, both for students considering careers in medicine and for individuals who have already entered or completed medical school. Given the frequency with which premedical college students shadow physicians, the lack of studies on shadowing by this group is surprising. One potential explanation is that premedical students often shadow on an informal basis rather than through programs sponsored by academic institutions. However, as shadowing by college students affects a significant number of patients, further research on its purposes, process, and impact is warranted. It is noteworthy that the majority of studies in this review involved shadowing programs outside the United States. Perhaps medical educators can learn from these reports how shadowing might be used effectively in the United States.

The data from the studies reviewed suggest that the majority of shadowing programs met their goals. Physician shadowing by high school, college, and medical students generally increased students’ interest in medicine and/or certain specialties. Physician shadowing by pre-PRHOs and IMGs enhanced participants’ confidence and competence, as measured by surveys. Qualitative analysis provided rich contextual data to support these conclusions. Whereas quantitative research can determine whether a program is successful in achieving its goals, qualitative research can help explain why.19

Additional studies measuring objective outcomes would complement the existing analyses. Although tracking the career choices of High School Rural Scholars or college students participating in a surgery shadowing program would be challenging, doing so would establish the percentage of participants who later become rural physicians or complete surgical residencies, respectively. This might provide objective evidence that physician shadowing experiences actually influence students’ career decisions. A mixed-methods approach to such research could help determine the degree to which shadowing, compared with other factors, plays a role in career choices. It would be optimal to include a control group of students who did not participate in shadowing.

Objective outcome measures could also contribute to research evaluating the impact of shadowing programs designed for pre-PRHOs and IMGs. For example, data showing improvements in medically relevant measures of PRHO performance (e.g., reduction in number of medical errors after shadowing) would provide more substantial evidence that shadowing has a positive effect, not only on trainee confidence but also on patient care. Similar data on IMG performance would be useful as well.

Our analysis was complicated by the fact that 11 of the 13 included articles were about programs that included both shadowing and other educational interventions. It is possible that the other experiences may have been the main contributors to the reported program outcomes. In addition, participants identified shadowing as the most critical program component in less than half of these 10 publications. It may be that multicomponent programs provide better learning experiences, but it is difficult to determine the effect of shadowing alone in such programs.

Similarly, the experience of pre-PRHOs who began as shadowers but progressed to providing active clinical care toward the end of the program period is not an accurate representation of shadowing13; rather, it would be better described as an apprenticeship. The concept of an apprenticeship is intuitively appealing: The pre-PRHO is gradually introduced to his or her future work environment and increasingly assumes responsibilities over time, rather than simply observing someone else doing the job. Apprenticeships could potentially improve the care provided to patients, especially those treated during house staff transitions. Although such shadowing/apprenticeship programs are used primarily in the United Kingdom, this approach could be useful in the United States and elsewhere as a mechanism for helping recent medical school graduates prepare for and ease into their internships.

Practical and ethical concerns

One publication1 raised practical and ethical concerns related to informal shadowing—that is, students shadowing physicians who are family members or acquaintances, in the absence of a structured program. Informal shadowing may lead to problems including undefined roles, negative effects on other learners, and inadequate infection control, as well as to issues related to credentialing and patient confidentiality. Our review of the literature suggests that even formal shadowing programs are not well defined or consistent and may therefore be subject to the same problems as informal experiences. A UK study similarly found variation among shadowing programs; its authors noted that students complained of poor timing, poor content, and little knowledge by the physician supervisor about the purpose of the shadowing experience.20

In addition, 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.

A proposal for physician shadowing guidelines

We propose the development of a handbook on physician shadowing for use by premedical students and the physicians they shadow in order to enhance the consistency of shadowing experiences and to address ethical and practical considerations. We recommend that it include the following content:

  • Goals of physician shadowing experiences
  • Academic requirements for participation
  • Roles and responsibilities of physicians and students
  • Student code of conduct (with an agreement for students to sign)
  • Patient privacy and confidentiality/Health Insurance Portability and Accountability Act (HIPAA) (with a confidentiality agreement for students to sign)
  • Informed consent (with a form for patients to sign)
  • Infection control

The handbook should also provide sample metrics for assessing students’ experiences and/or program success. These might include the number of days/weeks that each student spent shadowing, numbers of patient encounters the student observed, whether informed consent was obtained for each patient encounter, and a Likert scale that the student could use to indicate whether the experience affected his or her interest in pursuing a career in medicine. The handbook could be created by premedical advisors and medical students in collaboration with a national organization such as the Association of American Medical Colleges and/or the American Medical Association. Online publication and/or widespread dissemination of such a handbook to college and university premedical programs, medical schools, and practicing physicians could help ensure that shadowing, even when arranged informally, is conducted in a way that is optimal for all parties involved. The content of the handbook could be adapted as needed to address shadowing by individuals at other training levels.

As the list above suggests, we believe that college students should complete HIPAA training, sign a confidentiality agreement, and complete infection control requirements before they begin shadowing physicians. We also propose that they agree to follow a code of conduct, such as the one we developed (Appendix 1) after reviewing several medical student codes of conduct.21–24

It is important to keep in mind that although guidelines and confidentiality agreements could help minimize potential practical and ethical problems associated with shadowing, they cannot completely protect patients. A patient who grants informed consent to allow a student to observe an encounter with his or her physician may do so because of a power imbalance with the physician, or because the patient does not want to disappoint the physician. Moreover, with the student present, the patient may choose not to disclose sensitive, but clinically important, information to the physician.

Limitations

Limitations of this review include the fact that one database was searched, the small number of publications identified overall, the very small number of publications that evaluated shadowing alone, the relatively small sample sizes of individual publications, and variations in purposes and processes among the programs. In addition, sampling bias leading to self-selection of students already interested in medicine or a particular specialty may have influenced the outcomes of the studies involving high school, college, and medical students. Recall bias may also have confounded the analyses in the studies reviewed because the majority of the data were collected after the completion of programs. In addition, publications did not report all details of the programs.

Conclusion

Physician shadowing is a common practice, but reasons for participation vary according to the group involved. Shadowing may help high school and college students make career decisions and help medical students choose specialties. In the United Kingdom, shadowing eases graduating medical students’ transitions to house officer positions. Finally, shadowing allows IMGs to become familiar with the health care system they are entering.

Although shadowing is generally valued by participants, its impact has not yet been clearly demonstrated. The dearth of studies on shadowing and the variability of programmatic goals, processes, and participants make it difficult to determine its effectiveness. Developing a handbook with guidelines for physician shadowing, and adapting the content to the level of the student or trainee, could enhance the consistency of the experience and help address ethical concerns.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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