Survey of Osteopathic Medical Students Regarding Physician Shadowing Experiences Before and During Medical School Training

Abstract

Introduction:
Shadowing a physician is an observational experience which includes a student observing a licensed healthcare provider caring for patients. Shadowing is commonly done by students before and during medical school, but little is known about the nature or extent of these extra-curricular observational experiences.

Objective:
We hypothesized that shadowing experiences were common yet variable. We investigated the prevalence, nature, and perceived value of medical student experiences with shadowing physicians (both before and during medical school).

Methods:
This survey-based study was non-experimental with a cross-sectional convenience sample of osteopathic medical students about their shadowing experiences before and during medical school. The survey was sent to all matriculated osteopathic medical students (OMS1-4) for the 2017 to 2018 academic year from two medical schools: Philadelphia College of Osteopathic Medicine (PCOM) (1084 total students) and PCOM-Georgia (554 total students). The final survey instrument included three sections: demographics (6 questions), pre-medical shadowing experiences (21 questions), and medical student shadowing experiences (24 questions).

Results:
Respondents (357) identified themselves as OMS1 (96), OMS2 (89), OMS3 (73), OMS4 (95) and other (2, OMS5) with enrollment at PCOM-Philadelphia (242) and PCOM-Georgia (115). Among survey respondents, 339 (95.5%) reported shadowing a physician as a pre-medical student, and 110 (30.8%) reported shadowing (outside of their required clinical rotations) a physician during medical school. Requirements to participate were inconsistent; fewer than 50% of shadowing experiences required Health Insurance Portability and Accountability Act of 1996 (HIPAA) training, proof of vaccination, or purified protein derivative (PPD) documentation. In addition to observation, pre-medical and medical students, respectively, participated in history taking (44 [13%], 47 [42.7%]), physical examinations (45 [13.3%], 44 [40%]) and procedures (13, [3.8%], 20 [18.2%]) during their shadowing experiences. Motivations to participate in shadowing varied between pre-medical and medical student experiences, but both groups mentioned their desire to learn more about a particular discipline, obtain letters of recommendation, and gain patient care experience. Students recommended both pre-medical (273 [80.5%]) and medical school (93 [84.5%]) shadowing to future students.

Conclusion:
Shadowing remains a common and important tool for students to learn about patient care, medicine and careers. The nature of each shadowing experience and participation requirements are quite variable. Measures to ensure patient safety, confidentiality, liability and supervision are inconsistently applied. Promoting guidelines, as well as codes of conduct, for shadowing could serve as a helpful resource for students, academic advisors and supervising clinicians.

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DOI: 10.1177/2382120519852046
Introduction
Shadowing a physician is an experience defined as observing a
licensed healthcare provider caring for patients.1 The goal is to
offer an introduction into medicine, a glimpse into a specific
medical specialty and the daily responsibilities it might include,
as well as give the provider the opportunity to model profes-
sional behavior and exemplary care of patients.1
Physician clinical shadowing is common for undergraduate
students hoping to apply to medical school in an extremely
competitive application process.2 In a 2003 study that surveyed
pre-medical students attending a small, liberal arts college,
80.20% of them had shadowed a physician on at least one
occasion.3 Why such a common practice among students
applying to medical school? Shadowing has been encouraged
by pre-medical advisors as a way to show genuine interest in
the medical field, as well as to gain an awareness of the day-to-
day duties of a clinician.2 It is generally recommended that
applicants applying to medical school shadow a clinician1,2,4
and obtain a letter of recommendation from a clinician.5 A
large number of premedical students apply to both MD and
DO schools;6 shadowing provides an opportunity to learn
more about osteopathic medicine. Of the 39 osteopathic pro-
grams identified in the Osteopathic Medical College
Information Book 2018 to 2019, 22 require letters of
Survey of Osteopathic Medical Students Regarding
Physician Shadowing Experiences Before and During
Medical School Training
Erik Langenau1, Sarah B Frank1, Sarah J Calardo2
and Michael B Roberts1
1Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA. 2Inova Children’s Hospital,
Falls Church, VA, USA.
ABSTRACT:
INTRODUCTION: Shadowing a physician is an observational experience which includes a student observing a licensed healthcare provider
caring for patients. Shadowing is commonly done by students before and during medical school, but little is known about the nature or extent
of these extra-curricular observational experiences.
OBJECTIVE: We hypothesized that shadowing experiences were common yet variable. We investigated the prevalence, nature, and per-
ceived value of medical student experiences with shadowing physicians (both before and during medical school).
METHODS: This sur vey-based study was non-experimental with a cross-sectional convenience sample of osteopathic medical students
about their shadowing experiences before and during medical school. The survey was sent to all matriculated osteopathic medical students
(OMS1-4) for the 2017 to 2018 academic year from two medical schools: Philadelphia College of Osteopathic Medicine (PCOM) (1084 total
students) and PCOM- Georgia (554 total students). The final survey instrument included three sections: demographics (6 questions), pre-
medical shadowing experiences (21 questions), and medical student shadowing experiences (24 questions).
RE S ULTS : Respondents (357) identified themselves as OMS1 (96), OMS2 (89), OMS3 (73), OMS4 (95) and other (2, OMS5) with enrollment
at PCOM-Philadelphia (242) and PCOM-Georgia (115). Among survey respondents, 339 (95.5%) reported shadowing a physician as a pre-
medical student, and 110 (30.8%) reported shadowing (outside of their required clinical rotations) a physician during medical school.
Requirements to participate were inconsistent; fewer than 50% of shadowing experiences required Health Insurance Portability and Account-
ability Act of 1996 (HIPAA) training, proof of vaccination, or purified protein derivative (PPD) documentation. In addition to observation, pre-
medical and medical students, respectively, participated in history taking (44 [13%], 47 [42.7%]), physical examinations (45 [13.3%], 44
[40%]) and procedures (13, [3.8%], 20 [18.2%]) during their shadowing experiences. Motivations to participate in shadowing varied between
pre-medical and medical student experiences, but both groups mentioned their desire to learn more about a particular discipline, obtain let-
ters of recommendation, and gain patient care experience. Students recommended both pre-medical (273 [80.5%]) and medical school
(93 [84.5%]) shadowing to future students.
CONCLUSION: Shadowing remains a common and important tool for students to learn about patient care, medicine and careers. The nature
of each shadowing experience and participation requirements are quite variable. Measures to ensure patient safety, confidentiality, liability
and supervision are inconsistently applied. Promoting guidelines, as well as codes of conduct, for shadowing could serve as a helpful
resource for students, academic advisors and supervising clinicians.
KEYWORDS: shadowing, premedical shadowing, medical school shadowing, medical education
RECEIVED: April 15, 2019. ACCEPTED: April 26, 2019.
TYPE: Original Research
FUNDING: The author(s) re ceived no  nancia l suppor t for the research, a uthors hip, and/or
publication of this article.
DECLARATION OF CONFLICTING INTERESTS: The author(s) dec lared no po tential
conic ts of inter est with re spect to t he resear ch, autho rship, an d/or publ icatio n of this
article.
CORRESPONDING AUTHOR: Erik Langen au, Philad elphia C ollege o f Osteopa thic
Medic ine, 4170 City Avenue, Ph iladelp hia, PA 19131, USA. Email: erik la@pcom.edu
852046MDE0010.1177/2382120519852046Journal of Medical Education and Curricular DevelopmentLangenau et al
research-article2019

2 Journal of Medical Education and Curricular Development
recommendation from a physician, one recommends a letter
from a physician, and 16 do not specify. Of the 22 which
require letters from a physician, three require letters from a
DO, eight recommend letters from a DO, and three specifi-
cally require a shadowing experience with the specific DO who
is writing the letter.5 Shadowing experiences provide appli-
cants with the opportunity to learn about the field of medicine
and to obtain a letter of recommendation.
Shadowing is also common among students who have
already matriculated into a medical school. Third year medical
students report feeling inadequately prepared for the transition
to rotations, and course directors acknowledge the start of the
clinical education years is often difficult.7 As an additional
strategy to assist students in their transition to clinical educa-
tion with real patients, medical schools have established men-
toring and shadowing programs for medical students.8 This
opportunity to shadow in specialties of interest during the first
2 years was deemed particularly useful by the medical students.8
In addition to clinical rotations and formally arranged observa-
tional experiences by the medical school, it is likely that medical
students participate in independently arranged shadowing
experiences without the school administration’s knowledge.
Most medical students seem incredibly familiar with shad-
owing, having had several instances throughout pre-medical
and medical education where they were encouraged to partici-
pate in some form of physician observation. However, there
appears to be a lack of data, especially within the osteopathic
medical profession, regarding the prevalence, nature, require-
ments and motivations for participating in these shadowing
experiences. We hypothesized students frequently participated
in shadowing experiences before and during medical school,
but wanted to better understand the prevalence, nature and
perceived value of these shadowing experiences (both before
and during medical school). Focusing our attention only on
these extra-curricular observational experiences, we excluded
all clinical rotations, philanthropic, paid, or research-based
experiences. Through survey responses, we collected details
regarding the shadowing experience (setting, discipline,
required paperwork and pre-requisites, duties, and responsibili-
ties), required clinical or procedural skills, and perceived value
in terms of career guidance or professional preparedness.
Methods
This survey-based study was nonexperimental with a cross-
sectional convenience sample of first, second, third and fourth
year osteopathic medical students that asked about their shad-
owing experiences before and during medical school. The
institutional review board for the Philadelphia College of
Osteopathic Medicine (PCOM) approved this study.
Sample
Using PCOM’s email database, an email invitation to partici-
pate was sent to all current matriculated osteopathic medical
students (OMS) for the 2017 to 2018 academic year. The sam-
ple included first, second, third, and fourth year osteopathic
medical students from two medical schools: PCOM (1084
total students) and Philadelphia College of Osteopathic
Medicine Georgia Campus (PCOM-Georgia, 554 total stu-
dents). The survey link was emailed and available to students
between April 9 and May 8, 2018. The initial invitation to par-
ticipate was followed by two emailed reminders.
Survey development
After reviewing shadowing programs’ characteristics and out-
comes reported by other investigators,9 survey questions were
developed by two investigators (one physician and one fourth
year medical student), and revised after soliciting input from
three physicians familiar with shadowing and undergraduate
medical education. Questions were then uploaded and format-
ted to SurveyMonkey. After testing by three medical students,
two physicians and one administrator, survey formatting and
grammar enhancements were applied. The final survey instru-
ment included three sections: demographics (6 questions), pre-
medical shadowing experiences (21 questions), and medical
student shadowing experiences (24 questions). Questions
regarding shadowing experiences addressed setting, discipline,
required paperwork and pre-requisites, duties, responsibilities,
and perceived value. Students were also provided the opportu-
nity to share any other comments (open-ended response)
regarding their shadowing experience before and/or during
medical school. Survey participants were instructed to answer
questions limiting their shadowing experiences to extra-curric-
ular observational experiences only, excluding all clinical rota-
tions, philanthropic, paid, or research-based experiences.
Analysis
Data (descriptive statistics) from the survey were extracted from
Survey Monkey using Microsoft Excel 2016. Responses to open-
ended questions were first reviewed by one investigator who
identified themes for responses for each of the questions.
Responses and themes were reviewed and verified by a second
investigator. Responses were then categorized into different
themes by one investigator, reviewed, and verified by the second
investigator. The statistical analysis was performed using
Microsoft Excel 2016 and Statistical Package for Social Sciences
(SPSS). Descriptive statistics were initially computed and con-
sisted of percentages and frequencies for two independent groups
of shadowing before medical school and shadowing during medi-
cal school. Following the descriptive data, χ2 tests were used to
evaluate specific hypotheses in regard to differences between cat-
egorical groups. Both the goodness of fit and test of independ-
ence were utilized depending on the number of categorical
variables being examined. The two groups (before medical school
and during medical school) were considered independent of one
another. A significance value of α = .05 was accepted.

Langenau et al 3
Results
The survey was completed by 357 students: 242 enrolled stu-
dents from PCOM (22.3% response of 1084) and 115 students
from PCOM-Georgia (20.8% response of 554). Respondents
identified themselves as OMS1 (98, 27.5%), OMS2 (89,
24.9%), OMS3 (73, 20.5%), OMS4 (95, 26.6%) and OMS5 (2,
0.6%). Medical students identified themselves as female (224,
62.8%), male (133, 37.3%), age 22 to 24 (82, 23.0%), age 25 to
27 (172, 48.2%), 28 to 30 (72, 20.2%), 31 to 35 (23, 6.4%), older
than 36 (7, 2.0%), Caucasian (223, 64.8%), Asian (57, 16.6%),
African American/Black (18, 5.2%), Hispanic/Latino (9,
2.6%), Indian (10, 2.9%), and Other/Mixed (28, 8.1%). When
asked to account for their time between undergraduate training
and medical school, responding students reported, “I took no
time off between undergraduate and medical school” (76,
14.3%), “I worked (odd jobs or temporary employment)” (143,
27.0%), “I worked (previous career)” (85, 16.0%), “I traveled”
(38, 7.2%), “I completed additional course work (graduate or
post-baccalaureate studies)” (161, 30.4%) and “other” (27,
7.6%). “Other” responses included spending time with family,
military, research, and volunteer experiences.
Responses regarding logistics and details of shadowing
experiences before and during medical school are presented in
Table 1. Students reported they spent time shadowing clini-
cians before (339, 95.5%) and during (110, 30.8%) medical
school. Of those who reported shadowing a DO before medi-
cal school (204, 60.2%), the following were identified as rea-
sons for doing so (open-ended responses): curiosity about
osteopathic medicine (58, 28.4%), application requirement (56,
27.5%), convenience/familiarity (38, 18.6%), and exploration
of differences between MDs and DOs (26, 12.7%). Of those
students who shadowed a DO during medical school (62,
56.4%), the following reasons were cited: convenience/famili-
arity (10, 16.1%), desire to learn how DOs practice medicine
(7, 11.3%), coincidence (6, 9.7%), networking (5, 8.1%), desire
to differentiate MDs from DOs (3, 4.8%), and program
requirement (1, 1.6%).
Of those who reported shadowing experiences before medi-
cal school included history taking (44, 13.0%), specific ele-
ments cited elements included history of present illness (18,
40.9%), chief complaint (4, 9.1%), complete history (4, 9.1%),
and miscellaneous conversation (2, 4.5%). Of those who
reported history taking to be a part of their medical student
shadowing experiences (47, 42.7%), specific elements included
complete history (14, 29.8%), miscellaneous conversation (3,
6.4%), and chief complaint (2, 4.3%).
Of those who reported physical examination was involved
with their shadowing experience before medical school (45,
13.3%), elements included pulmonary exam (15, 33.3%), car-
diac exam (14, 31.1%), verification of abnormal findings (9,
20.0%), vital exam (9, 20.0%), complete physical exam (5,
11.1%), ENT exam (3, 6.7%), musculoskeletal exam (2, 4.4%),
abdominal exam (1, 2.2%), and visual exam (1, 2.2%). Of those
who reported physical examination was also part of shadowing
experiences during medical school (44, 40.0%), specific ele-
ments included complete physical exam (8, 18.2%), musculo-
skeletal exam (8, 18.2%), partial physical exam (4, 9.1%), and
pathology exam (2, 4.5%).
Of those reporting performing or assisting with procedures
(13, 3.8%) during their shadowing experience before medical
school, specific procedures included suturing (4, 30.8%), injec-
tions (3, 23.1%), phlebotomy (3, 23.1%), incision and drainage
(2, 15.4%), nerve conduction testing (1, 7.7%), ear irrigation (1,
7.7%), and lumbar puncture (1, 7.7%). Of those reporting shad-
owing experiences during medical school included performing
or assisting with procedures (20, 18.2%), specific procedures
included various surgical procedures (4, 20.0%), emergency
room (ER) procedures (4, 20.0%), injections (3, 15.5%), phle-
botomy (3, 15.5%), osteopathic manipulative treatment (2,
10.0%), chest tube placement (1, 5.0%), and autopsy (1, 5.0%).
Among reasons cited for wanting to shadow a clinician
before medical school (Table 2), “to learn more about medicine
in general” (108, 37.5%), “to learn more about a specific medi-
cal specialty/discipline” (47, 16.3%), and “to enhance medical
school application” (41, 14.2%) were identified as the most
important.
Among reasons identified for wanting to shadow a clinician
during medical school (Table 3), “to learn more about a specific
medical specialty/discipline” (56, 56.5%), “to learn more about
medicine in general” (13, 13.1%), and “to gain clinical experi-
ence” (9, 9.1%) were reported as the most important.
Shadowing experiences before medical school increased
desire to attend medical school (242, 71.4%), while experiences
during medical school increased desire to become a physician
(78, 70.9%). Students reported frustrations, such as those
included in Table 4 (eg, difficulty finding shadowing opportu-
nities, limited exposure with patients, etc) regarding shadowing
experiences before and during medical school. However, stu-
dents overwhelmingly recommended shadowing before (273,
80.5%) and during (93, 84.5%) medical school for future
students.
Discussion
We found shadowing before and during medical school to be
common. Like other investigators,9 we were surprised by the
general lack of research and literature regarding shadowing
experiences. The majority of students in this study chose to
shadow a clinician prior to medical school in order to learn
more about medicine in general, and many specifically chose to
shadow a DO. Students chose to shadow a DO to better
understand osteopathic philosophy, gain insight into the daily
practices of a DO, and compare MDs and DOs. The shadow-
ing opportunity provided them with the insight required to
make an application decision and likely contributed to their
decision to pursue an osteopathic medical education. Consistent
with published application resources for osteopathic medical

4 Journal of Medical Education and Curricular Development
Table 1. Logistics: shadowing experiences before and during medical school, response summary (n = 357).
SHADOWING EXPERIENCES
SURVEY RESPONSE
BEFORE MEDICAL
SCHOOLa
DURING MEDICAL
SCHOOLb
Did you participate in shadowing experiences with a
physician (DO or MD)?c
Yes 3 39 (95.5%) 110 (30.8 % )
No 16(4.5%) 191 (5 3. 5%)
How would you categorize the physician(s) (DO or MD) you
shadowed?
Primary care physician 200 (59.0%) 36 (32.7%)
Subspecialty physician 168 (49.6%) 43 (3 9.1%)
Surgical subspecialty physician 159 (4 6. 9%) 33 (30.0%)
ER/urgent care physician 91 (2 6. 8%) 31 (28. 2%)
Other 2 (0.6%) 0 (0.0%)
Did you shadow a DO (osteopathic physician)? Yes 204 (60.2%) 62 (56.4%)
No 84 (24. 8%) 37 (33.6%)
In approximately how many shadowing experiences did you
participate?c
1-2 experiences 57 (16.8%) 59 (53.6%)
3-5 experiences 114 (33.6%) 22 (20.0%)
6-8 experiences 45 (13.3%) 9 (8.2 %)
9 or more experiences 72 (21. 2%) 9 (8.2 %)
In which of the following settings were the shadowing
experiences held?c
Private of ce 200 (59.0%) 44 (40.0%)
Hospital (inpatient) 189 (55 .8%) 39 (35.5%)
Emergency room 114 (33.6%) 33 (30.0%)
Hospital-based outpatient clinic/
ofce
12 7 ( 37. 5%) 3 0 (27.3% )
Community health center 4 0 (11.8%) 14 (12.7%)
Other 6 (1. 8%) 7 (6.4%)
What was the average duration (length of time) for each of
these shadowing experiences?c
4 hours or less 31 (9 .1%) 29(26.4%)
1 day 83 (24. 5%) 34 (30 .9 %)
1 week 46 (13.6%) 13 (11. 8 %)
1-4 weeks 56 (16. 5%) 10 (9 .1%)
more than 1 month 72 (21. 2%) 13 (11.8% )
Outside of your required clinical rotations, when did you
participate in these shadowing experiences?
During OMS 1 Year N/A 61 (55.5%)
During OMS2 Year 3 0 (2 7. 3%)
During OMS3 Year 13 ( 11. 8 %)
During OMS4 Year 8 (7.3% )
During OMS5 Year 1 (0.9%)
Between OMS1 and OMS2 years 42 (38.2 %)
Between OMS2 and OMS3 years 7 (6.4%)
Between OMS3 and OMS4 years 1 (0.9 %)
Between OMS4 and OMS5 years 2 (1.8%)

Langenau et al 5
SHADOWING EXPERIENCES
SURVEY RESPONSE
BEFORE MEDICAL
SCHOOLa
DURING MEDICAL
SCHOOLb
Weekday(s) (daytime) 21 (19.1% )
Weekday(s) (evenings/nights) 16 (14 .5 %)
Weekend(s) 22 (20.0%)
School break(s) 26 (23.6%)
How did you nd /locate these physicians/shadowing
experiences? (Free Text Response)c
Personal connections 153 (45.1%) 26 (23.6%)
Networking and searching 116 (34. 2%) 26 (23.6%)
College/university resources 65 (19. 2%) 7 (6.4%)
Employment/volunteering 38 (11 . 2 %) 0 (0.0%)
Other 3 (0.9 %) 0 (0.0%)
Student club/organizations 0 (0.0%) 41 ( 3 7. 3 %)
Did your college/university assist you in obtaining these
shadowing experiences?
Yes 7 3 (21.5 %) 18 (16.4%)
No 215 (6 3. 4%) 81 (73.6%)
What type of paperwork, training or certications were
required for you to shadow the physician(s)?
HIPAA training 163 (48.1%) 44 (40.0%)
Proof of vaccination 143 (42 . 2%) 46 (41.8 %)
PPD documentation 135 (39.8%) 45 (40.9 %)
Health Physical 48 (14. 2%) 23 (20 .9%)
Drug screen 41 (12 .1%) 12 (10.9%)
CPR/BLS Training 24 ( 7.1 %) 13 (11. 8 %)
Other 11 (3 . 2%) 11 (10.0%)
Other lab work 8 (2.4%) 3 (2.7%)
None 90 (26 .5%) 35 (31.8%)
What were your responsibilities during your shadowing
experience? (Free Text Response)c
Observation, Q&A 247 ( 72.9%) 73 (66 .4%)
History taking 21 (6 .2%) 2 3 (2 0. 9%)
Physical examination and taking
vitals
15 (4.4%) 18 (16 .4%)
Scribe 11 (3 . 2 %) 1 (0.9 %)
Assist with surgeries/procedures 11 (3 . 2 %) 7 (6.4%)
Research 7 ( 2 .1%) 1 (0.9%)
Osteopathic Manipulative
Treatment
0 (0.0%) 1 (0.9%)
Uncategorized 10 (2.9%) 5 (4.6%)
How were you introduced to the patient(s)? (Free Text
Response)
Premedical or medical student 137 (40.4%) N/A
Student 89 (26.3%)
Student interested in medicine/
becoming a doctor
40 ( 11. 8 %)
Table 1. (Continued)
(Continued)

6 Journal of Medical Education and Curricular Development
Table 2. Reasons identied as the most important reason for wanting
to shadow a clinician before medical school (premedical shadowing).
To learn more about medicine in general 108 (3 7. 5 %)
To learn more about a specic medical specialty/
discipline
47 (16 .3 %)
To enhance medical school application 41 (14 .2%)
To get a letter of recommendation 3 5 (12 .2%)
To gain clinical experience 31 (10 .8 %)
Other 19 (6.6%)
To satisfy requirements for undergraduate
studies (mandated by the school)
5 (1.7 %)
To follow recommendations from my student
advisor
2 (0.7%)
288 (10 0%)
Additional reasons for wanting to shadow a physician as a pre-medical student
included desire to conrm career choice (27), gain a better understanding
of medicine and/or healthcare (15), gain clinical experience (8), explore
subspecialties (4), personal benet/fulllment (8), obtain a required letter of
recommendation (5), and research (1).
Table 3. Reasons identied as the most important reason for
wanting to shadow a clinician during medical school (medical school
shadowing).
To learn more about a specic medical specialty/
discipline
56 (56.6%)
To learn more about medicine in general 13 (13.1%)
To gain clinical experience 9 ( 9.1%)
Other 7 ( 7.1% )
To enhance residency application 5 (5.0%)
To return for a “second look” during residency
application
4 (4.0%)
To get a letter of recommendation 2 (2.02%)
To prepare for OMS3 and OMS4 years (clinical
years)
2 (2.0%)
To follow recommendations from my student
advisor
1 (1.0%)
99 (100%)
Additional reasons for wanting to shadow a physician as a medical student
included desire to gain more clinical experience (15), regain inspiration (3),
conrm career choice (3), network (3), satisfy program requirement (2),
participate in military experience (1), participate in research (1), and shadow at a
desired residency (1).
SHADOWING EXPERIENCES
SURVEY RESPONSE
BEFORE MEDICAL
SCHOOLa
DURING MEDICAL
SCHOOLb
Never introduced 7 (2.1%)
Scribe 4 (1. 2%)
Did you perform any part of the history taking with the
patient(s)?c
Yes 44 (13.0%) 47 (42.7%)
No 244 (72.0%) 52 (47. 3 %)
Did you perform any part of the physical examination with
the patient(s)?c
Yes 45 (13.3%) 44 (4 0%)
No 243 (71.7%) 55 (50 %)
Did you perform any procedures (eg, phlebotomy or
surgical procedures) with the patient(s)?c
Yes 13 (3.8%) 20 (18.2 %)
No 27 5 (8 1.1%) 79 ( 71.8%)
HIPAA: Health Insurance Portability and Accountability Act of 1996; BLS: Basic Life Support; CPR: cardiopulmonary resuscitation; PPD: puried protein derivative.
(1) not all survey respondents answered all questions, (2) many questions allowed multiple responses to each question, (3) responses to free text questions were
categorized into one or more themes; therefore, responses to each question, by percent, do not add to 100%.
aPercentages in column “Before medical school” are based on those who reported participating in shadowing experiences before medical school (n = 339).
bPercentages in column “During medical school” are based on those who reported participating in shadowing experiences during medical school and outside of their
required clinical rotations (n = 110).
cP <.05. Chi-square tests for independence were performed between groups for each response.
Table 1. (Continued)
schools,5 pre-medical students also chose to shadow a DO
physician to obtain suggested letters of recommendation or to
satisfy osteopathic medical school application requirements. A
small number of students reported challenges with meeting
this requirement, reporting that they had difficulty finding DO
physicians to shadow. The requirement to shadow and obtain a
letter from a DO physician is a well-intended mechanism to
expose pre-medical students to osteopathic medicine, but the
requirement may be a barrier to some students who are unable
to find shadowing experiences before medical school.
In terms of primary responsibilities, the majority of pre-
medical students reported that their shadowing was purely
observational. The remaining stated that they were involved in
history taking, performing vitals and physical exam, scribing
the visit note, assisting with surgeries or procedures, or per-
forming other tasks. Given the nature of some of the reported
responsibilities (suturing, assisting with Cesarean Sections,

Langenau et al 7
Table 4. Motivation and outcomes: shadowing experiences before and during medical school, response summary (n = 357).
SHADOWING EXPERIENCES
SURVEY RESPONSE
BEFORE MEDICAL
SCHOOLa
DURING MEDICAL
SCHOOLb
Did you participate in shadowing experiences with a physician
(DO or MD)?c
Yes 3 39 (95.5%) 110 (30.8 % )
No 16(4.5%) 191 (53 .5%)
Do you feel the shadowing experience(s) increased your desire to
attend medical school or become a physician?
Yes 242 (71. 4%) 78 ( 70.9%)
No 19 (5.6%) 1 3 (11.8 % )
Not sure 23 (6 .8%) 8 (7.3%)
Other 4 (1. 2%) 0 (0.0%)
Do you feel these shadowing experience(s) enhanced your desire
to pursue a specic eld/discipline/specialty of medicine?
Yes N /A 74 ( 6 7. 3 %)
No 10 (9 .1%)
Not sure 13 (11.8% )
Other 2 (1. 8%)
Do you feel the shadowing experience(s) increased your clinical
knowledge?c
Yes 186 (54.9%) 8 6 (78.2%)
No 69 (20.4%) 5 (4.5%)
Not sure 32 (9.4%) 7 (6 .4%)
Other 1 (0.3 %) 1 (0.9%)
Do you feel these shadowing experience(s) as a medical student
better prepared you for clinical rotations (OMS3 and OMS4)?
Yes N /A 58 (52.7%)
No 15 (13. 6%)
Not sure 26 (23.6%)
If applicable, what was different about shadowing as a pre-
medical student versus shadowing as a medical student?
(Free Text Response)
Increased responsibilities N/A 28 (25.5%)
Increased respect by
patients and clinicians
7 (6.4%)
Increased expectations 6 (5.5%)
Increased sense of reward 5 (4. 5%)
Increased teaching
opportunities
4 (3.6%)
Gained and required more
clinical knowledge
4 (3.6%)
What did you nd frustrating or disappointing about your
shadowing experience?
(Free Text Response)
Nothing frustrating, N/A 78 (23.0%) 46 (41.8%)
Difculty nding shadowing
opportunities
43 (12.7%) 5 (4.5%)
Not understanding the
medical information
39 ( 11. 5 %) 6 (5. 5%)
Limited exposure 14 (4 .1% ) 0 (0.0%)
Limited hands on
experience
9 (2.7%) 27 (24.5%)
(Continued)

8 Journal of Medical Education and Curricular Development
SHADOWING EXPERIENCES
SURVEY RESPONSE
BEFORE MEDICAL
SCHOOLa
DURING MEDICAL
SCHOOLb
Limited time 8 (2.4%) 10 ( 9.1%)
Limited teaching 7 (2.1%) 0 (0.0%)
Bureaucracy 7 (2.1%) 0 (0.0%)
Being forced to shadow 5 (1.5 %) 0 (0.0%)
Disliked doctor/patient/
healthcare relationship
4 (1. 2%) 0 (0.0%)
Poor relationship with doctor 3 (0.9%) 0 (0.0%)
Lack of help from university 2 (0.6%) 0 (0.0%)
Didn’t nd connections 1 (0. 3%) 0 (0.0%)
Uncategorized 1 (0.3%) 9 (8. 2%)
What did you nd rewarding about your shadowing experience?
(Free Text Response)
Interacting with patients 83 (24.5%) 4 (3.6%)
Positive clinical learning
experience
78 (23.0%) 23 (20. 9%)
Exposure to specialty and
styles
58 (17.1%) 0 (0.0%)
Interacting with clinicians/
networking
54 (15.9 %) 14 (12.7%)
Career guidance (validation
and direction)
42 (12.4%) 18 (16 .4%)
Did not nd it rewarding 6 (1. 8%) 5 (4.5%)
Satised application
requirements
5 (1.5%) 0 (0.0%)
Application of clinical
knowledge
0 (0.0%) 15 (13. 6%)
Inspirational and
motivational
0 (0.0%) 15 (13. 6%)
Every thing 0 (0.0%) 5 (4.5%)
Uncategorized 2 (0.6%) 1 (0.9%)
Would you recommend shadowing a physician to future
stud ents?c
Yes 273 (80.5%) 9 3 (84. 5%)
No 6 (1.8%) 0 (0.0%)
Not sure 9 (2.7%) 6 (5.5%)
(1) Not all survey respondents answered all questions, (2) many questions allowed multiple responses to each question, and (3) responses to free text questions were
categorized into one or more themes; therefore, responses to each question, by percent, do not add to 100%.
aPercentages in column “Before medical school” are based on those who reported participating in shadowing experiences before medical school (n = 339).
bPercentages in column “During medical school” are based on those who reported participating in shadowing experiences during medical school and outside of their
required clinical rotations (n = 110).
cP <0.05. Chi-square tests for independence were performed between groups for each response.
Table 4. (Continued)
performing a lumbar puncture, incision/drainage, chest tube
placement), it is unclear if pre-medical students fully per-
formed the procedures, assisted in them, or simply observed.
Survey respondents likely over-stated their involvement in
these procedures, but further study would be of interest. A
majority reported shadowing increased their desire to attend
medical school, and most recommended shadowing for future
pre-medical students.
Shadowing was also common among medical students.
Unrelated to structured rotations or clinical exercises, medical
students were motivated to shadow a clinician by their desire to
learn more about a specific medical specialty/discipline, report-
ing that medical school clerkships often do not offer enough
time to fully experience a specialty. Through open-ended
responses throughout the survey, students also reported a desire
to explore additional subspecialties not necessarily seen during

Langenau et al 9
mandatory rotations. Most shadowing experiences during
medical school occurred during the first and second years of
training. Medical students found these extracurricular shadow-
ing opportunities through student club contacts, personal con-
nections and networking. Medical school administrators likely
do not know the extent or nature of these independently
arranged extracurricular shadowing experiences. Medical stu-
dents seemed very satisfied with their shadowing experiences,
reporting that shadowing experiences outside of required rota-
tions greatly enhanced their desire to become a physician.
Many believed that their medical school should have had a
larger role in facilitating shadowing opportunities, identifying
mentors, and integrating the osteopathic philosophy of hands-
on care. Students expressed desire for a database of accessible
physicians that would help them explore areas of clinical inter-
est. The vast majority (84.5%) of students recommended shad-
owing to future students during medical school, but many of
the comments suggested shadowing should not be required,
citing concerns with time management and studying demands.
Most would agree caring for patients is an honor, and stu-
dents, before and during medical school, must comply with
standards to ensure patient dignity, confidentiality, and safety.
However, fewer than 50% of shadowing experiences required
Health Insurance Portability and Accountability Act of 1996
(HIPAA) training, proof of vaccination, or PPD documentation.
Shadowing pre-requisites were notably inconsistent. Previous
investigators have called for the development of protocols, guide-
lines and codes of conduct for shadowing,9 and the American
Association of Medical Colleges (AAMC) published “Guidelines
for Clinical Shadowing Experiences for Pre-Medical Students”
in 2016.1 This AAMC publication emphasizes the observational
nature of shadowing. If patient care is provided (including taking
a history, conducting a physical exam, or performing procedures),
then it is not considered shadowing. We discovered a large num-
ber of shadowing experiences, particularly during medical school
that had included history taking, physical examination and proce-
dures. By definition, these experiences would not be considered
shadowing. Questions regarding consent, confidentiality, safety
and liability should be considered. There is clearly great reward
for the clinicians and students with regard to shadowing, but do
these clinicians follow recommended guidelines or protocols for
shadowing? This would be of interest in future study. Based on
the results of this study (as reported by students), protocols and
guidelines are not consistently applied, and opportunities to
improve consistency exist.
This study had a few limitations with opportunities for fur-
ther research. First, the study was limited to matriculated stu-
dents at two osteopathic training institutions, and findings may
not be generalizable. A national survey of all medical school
trainees would be of interest. Second, the survey response rate,
although high for a volunteer survey of this nature, did not
include the entire student body. Third, differences between
groups (ethnicity, for instance) were not investigated. In a
larger, more comprehensive study, exploring differences in
shadowing experiences between groups would be of interest.
Fourth, students were asked to report details of shadowing
experiences before starting medical school; this recall bias likely
confounded response accuracy. Fifth, the study excluded
research and paid positions; these experiences, while not con-
sidered observational or shadowing in nature, undoubtedly
influence a pre-medical student’s perspective regarding health
careers, specific healthcare disciplines and patient care. For
instance, medical school applicants often become scribes to
learn about healthcare professions, gain clinical experience, and
increase chances of matriculation at medical school.10 Further
study of all volunteer, paid, scribe, research and observational
experiences would be of interest. Sixth, given the non-observa-
tional nature of many of the activities reported by students, fur-
ther exploration of the extent to which they assisted in these
procedures would be of interest. Did the student observe, assist,
or perform arthrocentesis, for instance? Did the student exag-
gerate his or her participation in this procedure? Seventh, the
survey was lengthy and lacked redundant questions to evaluate
internal consistency of responses. Eighth, we did not conduct
interviews or focus groups with study participants, relying
instead only on their multiple choice and open-ended answers.
Further information would be helpful in better understanding
the nature and timing of some of the reported experiences, as
well as the motivations to participate in shadowing.
Conclusion
Shadowing is a common strategy to introduce potential
medical students to healthcare and to expose medical stu-
dents to different disciplines and experiences. Although sha-
dowing is traditionally considered limited to observation,
pre-medical and medical students are often taking histories,
conducting physical exams, and performing or assisting with
procedures. Measures to ensure patient safety, confidentiality,
liability, and supervision are inconsistently applied for many
shadowing experiences. Shadowing is valuable, but students
often shadow without clearly defined expectations, direction,
and procedures. Establishing safe standards and procedures
for shadowing could involve many stakeholders: undergradu-
ate institutions (pre-medical colleges), undergraduate and
graduate medical education programs, student organizations,
accrediting agencies, patient safety organizations, and clini-
cians who provide these important shadowing experiences.
Reviewing, expanding and increasing promotion of existing
guidelines,1 as well as codes of conduct, for shadowing could
serve as a helpful resource for students, academic advisors,
and supervising clinicians.
Acknowledgements
We wish to thank the 357 students who participated in this
study and provided thoughtful responses to the survey. We also

10 Journal of Medical Education and Curricular Development
wish to thank all clinicians who take time to provide invaluable
shadowing opportunities to pre-medical and medical students.
Author Contributions
EL and SJC provide substantial contributions to the concep-
tion and design, subject recruitment, and acquisition of data.
EL, SBF, and MBR provided substantial contributions to the
analysis and interpretation of data. EL, SJC, and SBF drafted
the article, reviewed content critically for important intellec-
tual content. EL, SJC, and SBF addressed reviewer comments,
conducted further analysis of data, provided substantial edits to
the revised manuscript, and reviewed content critically for
important intellectual content. EL gave final approval of the
version of the article to be published. EL, SJC, SBF, and MBR
agree to be accountable for all aspects of the work ensuring that
questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.
ORCID iD
Erik Langenau https://orcid.org/0000-0003-1483-3583
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