Professionalism
Student giving health advice to family and friends Simon Tso and Asim Yousuf Department of Education and Development, Warwick Medical School, University of Warwick, Coventry, UK SUMMARY Background: This study explored graduate-entry medical students’ experiences of health-advice requests from their family and friends. Methods: This was a descriptive thematic analysis study involving a convenience sample of medical students from the University of Warwick 4–year MB ChB graduateentry medicine programme. Each participating student attended a one-to-one semi-structured interview. Audio recordings of the interviews were transcribed verbatim and analysed thematically. Data saturation of the main themes was achieved following 14 interviews.
Findings: Of the 14 students, eight (57%) were males and six (43%) were females. Students were asked to advise on a range of human and veterinary health issues. They were prepared to offer advice on health issues that they felt competent to manage: for example, first-aid scenarios that a ‘reasonable layperson’ or a first-aider would be able to help with. The nature of health advice given by students became increasingly complex as they progressed through their degree programme; however, they generally refrained from giving advice on complex health issues and chose to refer the individual to seek
help from competent professionals instead. Discussion: Previous research highlighted inappropriate advice could delay individuals seeking help from competent professionals, resulting in adverse clinical outcomes; however, we recommend that students should not be discouraged to act as good Samaritans. Instead, educators could help them to explore the professionalism and ethical issues raised by these requests, and the practical ways of handling these requests sensitively through discussion of case scenarios with acceptable and inappropriate behaviours.
This study explored graduate-entry medical students’ experiences of health-advice requests from their family and friends
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222 219
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Some students reported it was a humbling experience to receive healthadvice requests despite their lack of experience
INTRODUCTION
R
esearch suggests that most doctors have provided health advice or treatment to family members at some stage of their career.1,2 Although it is a natural desire for doctors to help their loved ones, in the UK the General Medical Council (GMC) states that:
Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship. GMC 20133 Medical students receive health-advice requests outside medical school. In 2011, a British Medical Association survey of medical students reported that 91 per cent of respondents encountered health-advice requests from non-medical family and friends, with 60 per cent of respondents stating that they did not receive medical school advice on how to handle these situations.4
METHODS This descriptive thematic analysis study aimed to explore graduate-entry medical students’ experience of health-advice requests from their family and friends.5 Our ontological and epistemological standpoints align with the constructivist approach of Charmaz.6 As a medical doctor, ST received health-advice requests from non-medical family and friends throughout the undergraduate and postgraduate period, and developed the viewpoint that medical students should observe professional guidance when managing health-advice requests in off-duty settings by signposting individuals in need of assistance to seek help from competent professionals. The study participants were a convenience sample of medical
students from the University of Warwick 4–year MB ChB graduateentry medicine programme. The study was advertised to potential participants via the electronic mailing list of a medical student society. ST provided ad hoc bedside teaching to some students, but had no appraisal role and did not take part in any student assessment. Each participating student attended a one-to-one semi-structured interview at the Warwick Medical School campus. They were asked if they received health-advice requests from their family and friends, and to describe their experiences and responses. The audio-recordings of the interviews were transcribed verbatim and coded thematically. Transcripts from each interview were systematically coded and compared against the codes generated from previous interviews, enabling the refinement of the coding system and the construction of the themes. The students were invited to review their interview transcript as part of the respondent validation process; however, they did not return comments. Data saturation of the main themes was achieved following 14 interviews. ST consulted with AY, a Warwick medical student who did not take part in the study, on study development, data analysis and writing the article.
FINDINGS Participant profile The sample consisted of medical students from across all year groups. Of the 14 students, eight (57%) were males and six (43%) were females. The mean age of the group was 26.1 years (range 22–33 years; standard deviation 3.7 years). Seven out of 14 (50%) students had worked as an allied health care professional prior to the start of their degree programme, and the remainder had not.
Theme: context Students received health-advice requests from their family and friends on a range of issues, including acute health problems (e.g. syncope, sports injury and cellulitis), chronic diseases (e.g. ulcerative colitis) and generic health issues (e.g. nutrition). One student reported that she was asked to assess the forefoot of a friend’s horse. Theme: perception Some students reported it was a humbling experience to receive health-advice requests despite their lack of experience and training. Their family and friends expected and trusted them to provide timely, relevant and competent responses to their requests. This placed them in a position of power and authority; however, these expectations could be overwhelming and difficult to manage.
You do not want to say something if there is a risk that it could be wrong. Year–2 student, number 02 They were prepared to give health advice on minor issues that they felt competent and confident to deal with: for example, first-aid scenarios that a reasonable layperson or a first-aider would be able to help with.
I would talk about that [first aid] as someone who is a first-aider would talk about. Year 3 student, number 08 One student, who used to be a qualified reporting radiographer, described that he would be prepared to review the X–rays of family and friends if he was requested to do so. The nature of health advice that students were prepared to give became increasingly complex as they progressed
220 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222
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through their degree programme. A third-year student described that she was concerned that her friend’s presenting signs and symptoms could represent cellulitis, and directed the friend to seek formal treatment from a qualified doctor.
A friend showed me a picture and said her leg was swollen. I said go and see your GP, it’s probably cellulitis and you need antibiotics. Year–3 student, number 07 Nevertheless, they were generally reluctant to make a diagnosis or give advice on the treatment plans for their family and friends’ health issues. They always advised the person requesting health advice to seek formal help from competent health care professionals. They were concerned about the consequences of giving inappropriate health advice, and they were not always prepared to accept responsibility for adverse outcomes. Some students expressed frustration at being used by other people as a short cut to access health advice instead of seeking help through formal channels. There should be clear boundaries between their professional and private lives.
Some saw me as a quick access to the NHS. Year–4 student, number 03 Theme: situational judgment Students considered a range of issues before deciding on an appropriate response to healthadvice requests from their family and friends. The key issues that they considered were: • was the setting appropriate for me to give advice? • am I competent to give the advice?
• what were the potential adverse consequences if my advice was wrong? • was it ethical for me to give the advice? The example below illustrated how one final-year student arrived at the conclusion that he would not give out health advice to family and friends.
I am in more of a position with these people to infer some sort of personal preference onto them and to sway what they may think about a disease or treatment. I don’t want to be responsible for that. Year–4 student, number 03 Theme: responses There were four categories of responses: problem-orientated, appraisal-orientated, emotionfocused and avoidance. Some students advised on diagnosis or management of a health issue (problem-orientated response). Some acted as a health advocate to direct the persons seeking health advice to the appropriate health care professional, or to help them understand health information (appraisal-orientated response). Some provided social and emotional support (emotionfocused response), and some declined to offer any health advice (avoidance).
I am quite happy explaining to people what things are. Year–4 student, number 03 DISCUSSION Study participants showed an ambivalence towards health-advice requests, wishing to be helpful but not to give the wrong advice. Some justified that they could offer health advice on minor conditions, such as a sprained ankle, as they deemed that a reasonable layperson or first-aider would
be able to help with that. Some were also prepared to suggest diagnosis and management. Previous studies have shown, however, that inappropriate advice could delay individuals seeking help from competent professionals, resulting in adverse clinical outcomes.7
Inappropriate advice could delay individuals seeking help from competent professionals
We recommend that students must recognise the limitations of their role and act within established professional guidelines when handling health-advice requests in unsupervised off-duty settings, unless there were compelling reasons that necessitated their intervention.3 Nevertheless, students should not be discouraged to act as good Samaritans. Instead, educators could help them to explore the professionalism and ethical issues raised by these requests and the practical ways of handling these requests sensitively through discussion of case scenarios with acceptable and inappropriate behaviours. Such learning would best take place early on in their degree programme, as first-year students are already receiving requests for advice. This study had a number of limitations. It had a small convenience sample of graduate-entry medical students from a single medical school. The sample population had a higher percentage of male students compared with the national average.8 It was possible that participating students withheld information about any misdiagnosis or adverse outcome resulting from health advice that they had given because of social desirability bias. Nevertheless, the study findings contributed a small piece of the jigsaw towards our overall understanding of how medical students approach health-advice requests in off-duty settings and the professionalism issue of giving
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222 221
tct_12413.indd 221
4/22/2016 8:47:59 AM
Students should not be discouraged to act as good samaritans
health advice to family and friends. Future research could explore whether there were differences between undergraduate-entry and graduate-entry medical students’ decision making in responding to health-advice requests, and why their family and friends were motivated to seek health advice from the students. REFERENCES 1.
La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians’ treating their own families. JAMA 2002;267:1810–1812.
2.
Evans RW, Lipton RB, Ritz K. A survey of neurologists on self-treatment and treatment of their families. Headache 2007a;47:58–64.
3.
General Medical Council. Good medical practice: Prescribing guidance. Available at http://www.gmcuk.org/guidance/ethical_guidance/ 14318.asp. Accessed on 2 December 2014.
4.
British Medical Association. Students decide: are you happy to help? Available at http://bma. org.uk/news-views-analysis/ news/2011/october/studentsdecide-are-you-happy-to-help. Accessed on 20 September 2014.
5.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101.
6.
Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. London: Sage Publications Ltd; 2006.
7.
Evans J, Ziebland S, McPherson A. Minimizing delays in ovarian cancer diagnosis: an expansion of Andersen’s Model of ‘total patient delay’. Fam Pract 2007b;24:48–55.
8.
Garrud P. Who applies and who gets admitted to UK graduate entry medicine? – an analysis of UK admission statistics. BMC Medical Education 2011;11:71.
Corresponding author’s contact details: Dr Simon Tso, Educational Development and Research Team, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK. E-mail: [email protected]
Funding: The Institute of Advance Teaching and Learning, University of Warwick, funded the research study. Conflict of interest: None. Acknowledgements: The authors would like to thank Dr Jane Kidd, Dr Mandy Barnett and Mr John Lee for their comments on an earlier draft of the article. Ethical approval: This research study received a favourable opinion from the University of Warwick Biomedical Research Ethics subcommittee. doi: 10.1111/tct.12413
222 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222
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4/22/2016 8:47:59 AM
Student giving health advice to family and friends Simon Tso and Asim Yousuf Department of Education and Development, Warwick Medical School, University of Warwick, Coventry, UK SUMMARY Background: This study explored graduate-entry medical students’ experiences of health-advice requests from their family and friends. Methods: This was a descriptive thematic analysis study involving a convenience sample of medical students from the University of Warwick 4–year MB ChB graduateentry medicine programme. Each participating student attended a one-to-one semi-structured interview. Audio recordings of the interviews were transcribed verbatim and analysed thematically. Data saturation of the main themes was achieved following 14 interviews.
Findings: Of the 14 students, eight (57%) were males and six (43%) were females. Students were asked to advise on a range of human and veterinary health issues. They were prepared to offer advice on health issues that they felt competent to manage: for example, first-aid scenarios that a ‘reasonable layperson’ or a first-aider would be able to help with. The nature of health advice given by students became increasingly complex as they progressed through their degree programme; however, they generally refrained from giving advice on complex health issues and chose to refer the individual to seek
help from competent professionals instead. Discussion: Previous research highlighted inappropriate advice could delay individuals seeking help from competent professionals, resulting in adverse clinical outcomes; however, we recommend that students should not be discouraged to act as good Samaritans. Instead, educators could help them to explore the professionalism and ethical issues raised by these requests, and the practical ways of handling these requests sensitively through discussion of case scenarios with acceptable and inappropriate behaviours.
This study explored graduate-entry medical students’ experiences of health-advice requests from their family and friends
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222 219
tct_12413.indd 219
4/22/2016 8:47:58 AM
Some students reported it was a humbling experience to receive healthadvice requests despite their lack of experience
INTRODUCTION
R
esearch suggests that most doctors have provided health advice or treatment to family members at some stage of their career.1,2 Although it is a natural desire for doctors to help their loved ones, in the UK the General Medical Council (GMC) states that:
Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship. GMC 20133 Medical students receive health-advice requests outside medical school. In 2011, a British Medical Association survey of medical students reported that 91 per cent of respondents encountered health-advice requests from non-medical family and friends, with 60 per cent of respondents stating that they did not receive medical school advice on how to handle these situations.4
METHODS This descriptive thematic analysis study aimed to explore graduate-entry medical students’ experience of health-advice requests from their family and friends.5 Our ontological and epistemological standpoints align with the constructivist approach of Charmaz.6 As a medical doctor, ST received health-advice requests from non-medical family and friends throughout the undergraduate and postgraduate period, and developed the viewpoint that medical students should observe professional guidance when managing health-advice requests in off-duty settings by signposting individuals in need of assistance to seek help from competent professionals. The study participants were a convenience sample of medical
students from the University of Warwick 4–year MB ChB graduateentry medicine programme. The study was advertised to potential participants via the electronic mailing list of a medical student society. ST provided ad hoc bedside teaching to some students, but had no appraisal role and did not take part in any student assessment. Each participating student attended a one-to-one semi-structured interview at the Warwick Medical School campus. They were asked if they received health-advice requests from their family and friends, and to describe their experiences and responses. The audio-recordings of the interviews were transcribed verbatim and coded thematically. Transcripts from each interview were systematically coded and compared against the codes generated from previous interviews, enabling the refinement of the coding system and the construction of the themes. The students were invited to review their interview transcript as part of the respondent validation process; however, they did not return comments. Data saturation of the main themes was achieved following 14 interviews. ST consulted with AY, a Warwick medical student who did not take part in the study, on study development, data analysis and writing the article.
FINDINGS Participant profile The sample consisted of medical students from across all year groups. Of the 14 students, eight (57%) were males and six (43%) were females. The mean age of the group was 26.1 years (range 22–33 years; standard deviation 3.7 years). Seven out of 14 (50%) students had worked as an allied health care professional prior to the start of their degree programme, and the remainder had not.
Theme: context Students received health-advice requests from their family and friends on a range of issues, including acute health problems (e.g. syncope, sports injury and cellulitis), chronic diseases (e.g. ulcerative colitis) and generic health issues (e.g. nutrition). One student reported that she was asked to assess the forefoot of a friend’s horse. Theme: perception Some students reported it was a humbling experience to receive health-advice requests despite their lack of experience and training. Their family and friends expected and trusted them to provide timely, relevant and competent responses to their requests. This placed them in a position of power and authority; however, these expectations could be overwhelming and difficult to manage.
You do not want to say something if there is a risk that it could be wrong. Year–2 student, number 02 They were prepared to give health advice on minor issues that they felt competent and confident to deal with: for example, first-aid scenarios that a reasonable layperson or a first-aider would be able to help with.
I would talk about that [first aid] as someone who is a first-aider would talk about. Year 3 student, number 08 One student, who used to be a qualified reporting radiographer, described that he would be prepared to review the X–rays of family and friends if he was requested to do so. The nature of health advice that students were prepared to give became increasingly complex as they progressed
220 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222
tct_12413.indd 220
4/22/2016 8:47:59 AM
through their degree programme. A third-year student described that she was concerned that her friend’s presenting signs and symptoms could represent cellulitis, and directed the friend to seek formal treatment from a qualified doctor.
A friend showed me a picture and said her leg was swollen. I said go and see your GP, it’s probably cellulitis and you need antibiotics. Year–3 student, number 07 Nevertheless, they were generally reluctant to make a diagnosis or give advice on the treatment plans for their family and friends’ health issues. They always advised the person requesting health advice to seek formal help from competent health care professionals. They were concerned about the consequences of giving inappropriate health advice, and they were not always prepared to accept responsibility for adverse outcomes. Some students expressed frustration at being used by other people as a short cut to access health advice instead of seeking help through formal channels. There should be clear boundaries between their professional and private lives.
Some saw me as a quick access to the NHS. Year–4 student, number 03 Theme: situational judgment Students considered a range of issues before deciding on an appropriate response to healthadvice requests from their family and friends. The key issues that they considered were: • was the setting appropriate for me to give advice? • am I competent to give the advice?
• what were the potential adverse consequences if my advice was wrong? • was it ethical for me to give the advice? The example below illustrated how one final-year student arrived at the conclusion that he would not give out health advice to family and friends.
I am in more of a position with these people to infer some sort of personal preference onto them and to sway what they may think about a disease or treatment. I don’t want to be responsible for that. Year–4 student, number 03 Theme: responses There were four categories of responses: problem-orientated, appraisal-orientated, emotionfocused and avoidance. Some students advised on diagnosis or management of a health issue (problem-orientated response). Some acted as a health advocate to direct the persons seeking health advice to the appropriate health care professional, or to help them understand health information (appraisal-orientated response). Some provided social and emotional support (emotionfocused response), and some declined to offer any health advice (avoidance).
I am quite happy explaining to people what things are. Year–4 student, number 03 DISCUSSION Study participants showed an ambivalence towards health-advice requests, wishing to be helpful but not to give the wrong advice. Some justified that they could offer health advice on minor conditions, such as a sprained ankle, as they deemed that a reasonable layperson or first-aider would
be able to help with that. Some were also prepared to suggest diagnosis and management. Previous studies have shown, however, that inappropriate advice could delay individuals seeking help from competent professionals, resulting in adverse clinical outcomes.7
Inappropriate advice could delay individuals seeking help from competent professionals
We recommend that students must recognise the limitations of their role and act within established professional guidelines when handling health-advice requests in unsupervised off-duty settings, unless there were compelling reasons that necessitated their intervention.3 Nevertheless, students should not be discouraged to act as good Samaritans. Instead, educators could help them to explore the professionalism and ethical issues raised by these requests and the practical ways of handling these requests sensitively through discussion of case scenarios with acceptable and inappropriate behaviours. Such learning would best take place early on in their degree programme, as first-year students are already receiving requests for advice. This study had a number of limitations. It had a small convenience sample of graduate-entry medical students from a single medical school. The sample population had a higher percentage of male students compared with the national average.8 It was possible that participating students withheld information about any misdiagnosis or adverse outcome resulting from health advice that they had given because of social desirability bias. Nevertheless, the study findings contributed a small piece of the jigsaw towards our overall understanding of how medical students approach health-advice requests in off-duty settings and the professionalism issue of giving
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222 221
tct_12413.indd 221
4/22/2016 8:47:59 AM
Students should not be discouraged to act as good samaritans
health advice to family and friends. Future research could explore whether there were differences between undergraduate-entry and graduate-entry medical students’ decision making in responding to health-advice requests, and why their family and friends were motivated to seek health advice from the students. REFERENCES 1.
La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians’ treating their own families. JAMA 2002;267:1810–1812.
2.
Evans RW, Lipton RB, Ritz K. A survey of neurologists on self-treatment and treatment of their families. Headache 2007a;47:58–64.
3.
General Medical Council. Good medical practice: Prescribing guidance. Available at http://www.gmcuk.org/guidance/ethical_guidance/ 14318.asp. Accessed on 2 December 2014.
4.
British Medical Association. Students decide: are you happy to help? Available at http://bma. org.uk/news-views-analysis/ news/2011/october/studentsdecide-are-you-happy-to-help. Accessed on 20 September 2014.
5.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101.
6.
Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. London: Sage Publications Ltd; 2006.
7.
Evans J, Ziebland S, McPherson A. Minimizing delays in ovarian cancer diagnosis: an expansion of Andersen’s Model of ‘total patient delay’. Fam Pract 2007b;24:48–55.
8.
Garrud P. Who applies and who gets admitted to UK graduate entry medicine? – an analysis of UK admission statistics. BMC Medical Education 2011;11:71.
Corresponding author’s contact details: Dr Simon Tso, Educational Development and Research Team, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK. E-mail: [email protected]
Funding: The Institute of Advance Teaching and Learning, University of Warwick, funded the research study. Conflict of interest: None. Acknowledgements: The authors would like to thank Dr Jane Kidd, Dr Mandy Barnett and Mr John Lee for their comments on an earlier draft of the article. Ethical approval: This research study received a favourable opinion from the University of Warwick Biomedical Research Ethics subcommittee. doi: 10.1111/tct.12413
222 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2016; 13: 219–222
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4/22/2016 8:47:59 AM
