The conflict between legal norms and medical practice is great in teaching programs. The improper supervision and delegation of work is a perennial problem in medical care delivery, and it is most troublesome in teaching programs. The medical-ethics and medical-legal literature contain elaborate theories of patient autonomy and student supervision that represent the expectations of the law. They bear little resemblance to medical training, however. The usual practice in teaching hospitals and medical schools has been to use medical students and residents for patient care with little or no attention to their legal status. Patients are implicitly (and sometimes explicitly) deceived about who is a licensed physician and about their right to refuse to participate in teaching programs. [Asch DM, Parker RM. The Libby Zion case: one step forward or two steps backward? N Engl J Med. 1988;318:771–775.]

This conflict between legal expectations and medical practice has persisted for two reasons: (1) it is convenient for the physicians participating in the teaching programs, and (2) boards of medical examiners have had little interest in enforcing the provisions of the law that relate to patient autonomy and physician-endorsed unauthorized practice of medicine. Malpractice lawsuits become an issue only when a patient is severely injured. Even then, many programs are sheltered under various forms of governmental immunity, pushing the onus for paying the resulting claims onto any private physicians involved in the care of the injured patient.