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Fraud, both implicit and explicit, is a constant threat when medical students are involved in patient care. The fraud arises from the patient believing that the medical student is a licensed physician. Some health care providers even introduce medical students as "doctors" or as "young doctors." In this situation, the health care provider and the medical student have conspired to commit fraud upon the patient. This fraud can have significant legal consequences if the patient is injured by the medical student's actions. Since fraud is an intentional tort (unlike medical malpractice), the patient may recover for the injuries that result from the patient's reliance on the representation of the medical student as a physician. This would include recovery for any physical injuries that resulted from the medical student's rendering care, but it could also include recovery for certain emotional injuries that resulted from intimate disclosures that would not have been made to a nonphysician. The court is free to award punitive damages in cases of intentional torts such as fraud. These punitive damages are not dependent on the amount of actual damages; rather they are determined by the outrageous nature of the fraud. Even a minor injury may result in substantial punitive damages.

While punitive damages are a problem only in intentional fraud, unintentional fraud also has legal risks. Unintentional, or implicit, fraud occurs when the patient is led to assume that the medical student is a physician. This usually occurs when the patient encounters only a physician. The medical student is not introduced as a physician, but also is not introduced as a medical student. (This becomes intentional fraud if the patient addresses the student as "doctor" and is not corrected.) This situation becomes especially confusing if the student has a doctorate of philosophy or other doctoral-level degrees. In this case, it may be proper to address the student as "doctor," but it is also a fraud on the patient, who expects "doctor" to mean physician.

The best way to deal with the issue of what to call medical student is always to introduce them as medical students. They should wear name tags that clearly label them as students rather than tags that are coded so that other medical personnel can identify them but the patients cannot. These identifying tags are essential if the hospital employs contract nurses who are not familiar with the hospital codes. Students must be cautioned to correct patients who refer to them as "doctor" and to avoid letting a patient persist in the mistaken impression that they are physicians.

These policies are basic to risk management efforts concerning medical students, although they are often resisted by the medical staff. The risk manager should be prepared to answer the criticism that, if the students are not introduced as "doctor," the patients will not agree to be treated by them. This is, of course, the heart of the problem. If the patients do not want to be treated by medical students, tricking them into accepting this treatment will have grave legal consequences.

The experience of health care providers who are careful to identify medical students to their patients is that most patients are happy to be attended by the students. This is irrelevant to the legal issues of preventing fraud, but it does defuse the practical issues of teaching-staff politics and interference with clinical relationships. The risk manager must stress that patient acceptance of medical students is not a justification for misrepresenting them as physicians. This acceptance only strengthens the need to be hones with the patients, since misrepresentation would alienate patients who otherwise would be satisfied with the care they received.

The central legal problem is that it is precisely the patients who would refuse to be treated by medical students who must not be lied to about the students' status. If these patients suffer an adverse consequence of therapy, they may become very upset when they find that they were treated by students; and this would increase the likelihood of a lawsuit being filed in a situation that might otherwise have been settled informally. The loss of patient confidence is a serious risk management problem that can be avoided by careful attention to the proper identification of students.

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