Physicians who work with teaching services should be careful to protect their patients’ autonomy. Patients are entitled to control who is entrusted with their medical care and their medical information. Ethically, a patient’s method of payment, or the absence of payment, does not affect the right to receive care from a licensed physician. This is also the legal rule unless modified by state law. Although a state might pass a law conditioning the provision of charity care on the acceptance of care by students and residents, this might pose equal protection problems under the Constitution. If a patient who is brought into a county charity hospital that uses students and interns extensively in first- line care demands a “real doctor,” the hospital must produce a licensed physician to provide care. It is not acceptable to tell the patient that no physician is available.

Patients also are entitled to know, when they first seek care from a physician, whether they will be asked to participate in a teaching program. Private physicians who make teaching a part of their practice should inform their patients at the first patient visit that they are entering a teaching practice but that they have the right to refuse to be cared for by students and residents or by a given resident or student.

Patients should not be introduced to a student and then asked if they are willing to participate as teaching material. The patient should be asked first, out of the presence of the student. Most patients are willing to participate in teaching, but the physician must be prepared to honor the request of patients who do not want to participate. Ethically, the patient’s decision to accept or refuse to participate in a teaching program should have no bearing on whether the physician will treat the patient. Linking the participation in the teaching program to access to medical care creates an improper coercive atmosphere. Legally, the physician must honor the patient’s refusal but may refer the patient to another physician if the referral would otherwise be acceptable.

The physician should document the patient’s wishes as to participating in teaching. Once general permission is obtained, simple consent is required before a specific medical student or resident may participate in a patient’s care. This is obtained by introducing the student to the patient and asking the patient if the student may participate in the care. If the patient has concerns about privacy, the students and residents should be instructed to respect the patient’s wishes. Some teaching programs generally ignore concerns with privacy of medical information as regards students and residents, but they are not excluded from either the state or federal laws that govern access to medical information.