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Fall 2006
Volume 06, Number 1

Newsletter on Philosophy and Medicine

Articles

Breeding Cynicism: The Re-Education of Medical Students

Ben Rich
University of California–Davis

Introduction

The surgeon-author Richard Selzer writes the following in an introductory piece to a text entitled Ward Ethics―Dilemmas for Medical Students and Doctors in Training:

Medical students are so altruistic and humane when they start and then somewhere along the line they lose it, it’s beaten out of them. My own training as a surgeon is an example. Training in surgery has traditionally been carried out "en militaire." It was awful when I was in training because the brutality was handed down from the chiefs of surgery all the way to the chief resident, the intern, the medical students, and the nurses. We learned to pass on the brutality because it had been done to us and if you quailed or if you showed any kind of fear or sense of having been embarrassed, then you lost points and you were subject to further ridicule. It was a bad way to become a doctor because it was inhumane. You were brutalized emotionally, and sometimes physically, and it still goes on.1

Selzer’s view that students enter medical school brimming with altruism and flush with humane impulses, and only in the process of becoming a physician have this driven out of them, is not without its critics. A phenomenon characterized as the "premedical syndrome" has been recognized for decades.2 Its symptoms, if we are to stay within the genre of the pathological, include behaviors that are described as "overachieving, excessively competitive, cynical, dehumanized, over-specialized, and narrow."3 These behaviors are ostensibly reinforced by the obsessive focus of medical school admissions committees on certain numerical indicia of aptitude for medical school, i.e., grade point average (GPA), particularly GPA in the pre-medical sciences, and performance on the Medical College Admission Test (MCAT). While there has been some effort of late to incorporate more humanistic perspectives into the medical school admissions process, through required essays about why the prospective student wishes to become a physician, probing values-oriented questions in the campus interview process, and evidence of prior engagement in socially motivated extracurricular activities, the fact of the matter is that students without an outstanding GPA and high MCAT scores will not be admitted. Indeed, one can argue that it would not be fair or reasonable to admit such students because they would not have a realistic prospect of passing the rigorous basic science courses of the first two years that can be challenging even for those who entered with high GPAs and MCAT scores.4

However, for purposes of this paper, let us concede Selzer’s point and look for solid confirmatory evidence of the inhumanity of medical education. Recently, the medical school where I serve as bioethics faculty surveyed its fourth-year medical students about the treatment they had experienced in their third-year clerkships. While the precise results remain confidential, suffice it to say that they do nothing to discredit Selzer’s assertions in the above-quoted passage. Moreover, there is a wealth of additional data in the recent medical literature supporting the proposition that, as described by Selzer, medical students and residents perceive that their clinical training takes place in a hostile, and sometimes even abusive, atmosphere.5 At some point the persistence of this state of affairs morally implicates the faculty and administrators who are ultimately in control of, or at least responsible for, those venues of medical education. More specifically, that would include clerkship directors, residency directors, and clinical department chairs.

Hopefully, a closer examination of the culture of medical education will provide a basis for understanding the precise nature of the problem and formulating proposed solutions to it. Just such an inquiry was advocated in a provocative presentation by Leon Kass commemorating the twentieth anniversary of the Hastings Center, when he urged those in the field of medical ethics to devote more attention to "institutions and customs that help shape the profession of medicine, especially that influence the attitudes, sensibilities, and habits of medical practitioners as moral agents…what is praised and blamed, honored and held shameful, in medical training and medical practice."6 But overarching this inquiry and analysis is a still more fundamental question: How could any rational person, not to mention an entire profession, ever expect to fashion humane, compassionate, caring physicians in an educational environment characterized by harshness, rigidity, and cynicism?

The Culture of Medicine

Medical school constitutes the quintessential example of the process by which carefully selected laypersons are transformed into professionals. Because of the systematic progression of the student from the pre-clinical to the clinical years of undergraduate medical education, followed by the internship and residency training of postgraduate medical education, the amalgamation of education and enculturation is much more extensive than in other professional education settings such as law school. The traditional law school curriculum had the very modest goal of teaching students―in one year of required courses and two years of electives―to "think like a lawyer."7 The task of teaching law students how to actually practice law was deferred and implicitly delegated to the early employers of the recent law graduates. Law schools did not even prepare their students to pass the bar examination that is a prerequisite to practicing law in any jurisdiction. Law graduates had to expend additional time, effort, and money taking commercial bar review courses. Recently, some law schools have begun to shoulder a portion of this responsibility by incorporating legal practice skills courses. However, the elite law schools, and those that aspire to be considered in their ranks, continue to be subjected to the strong criticism that there is a persistent, and perhaps even expanding, gulf between legal education and legal practice.8 Traditional doctoral programs in philosophy have a similar pedagogical priority.

Medical education, by contrast, is a transformative process by which knowledge, skills, attitudes, indeed, an entire professional persona, are imparted. With even more refinement, as medical students in the fourth year decide what medical specialty they will enter, and begin to interview for residency slots in that specialty, the general professional persona of the physician begins to undergo a refinement process that exemplifies the wide disparity among physicians depending upon their area of specialization. The values and ways of being in the world of patient care of surgeons are radically different in important ways from those of family practitioners or psychiatrists. In a very real sense, medical students must decide not only what kind of medicine they want to practice but what kind of person they want to become and what medical ideology or creed they choose to adopt.

Yale surgeon and writer Sherwin Nuland, in his 1994 book How We Die, provides a vivid illustration of precisely this point in his discussion of his care of an elderly woman named Hazel Welch. In his dogged determination to convince the ninety-two-year-old Miss Welch to undergo major surgery to repair a life-threatening rupture of her duodenum, Nuland attempts to explain why he simply could not take "no" for an answer, despite the fact that it constituted the patient’s clearly informed refusal of the procedure:

The code of the profession of surgery demands that no patient as salvageable as Miss Welch be allowed to die if a straightforward operation can save her. …Viewed by a surgeon, mine was strictly a clinical decision, and ethics should not have been a consideration.9

In a few simple sentences Nuland sweeps into oblivion decades of legal and bioethical consensus about the rights of patients to determine their own medical fate. But this "Code of Surgery" is, according to Nuland, embedded in a still more fundamental fact about the intrinsic values of the medical profession, which he expresses in the following effusive prose:

The challenge that motivates most persuasively; the challenge that makes each of us physicians continue ever trying to improve our skills; the challenge that results in the dogged pursuit of a diagnosis and a cure; the challenge that has resulted in the astounding progress of late-twentieth-century clinical medicine―that foremost of challenges is not primarily the welfare of the individual human being, but, rather, The Riddle of his disease.10

Thus, from Nuland’s perspective, the core values of contemporary medicine not only deny the proposition that physicians should respect patient values but even challenge the idea that caring for patients, rather than solving the pathophysiological riddles that their diseases present, should be what motivates people to enter medicine in the first place. No one has captured the logical and moral fallacy of the view Nuland espouses more lucidly than Eric Cassell, who insists that "doctors do not treat diseases, they treat patients." Moreover, he observes that "the same disease in different individuals may have a different presentation, course, treatment, and outcome."11 It is because the proper focus of the physician must be the patient, not merely her disease, that the attributes of altruism and humaneness are as essential to the ideal physician as mere technical competence. Yet, as Cassell also observes, "these values are not central to the training programs of modern medical centers."12 In order to understand the process by which certain implicit values of medicine―in this case those espoused by Nuland, not Cassell―are imparted to medical students, we need to discern two quite disparate elements of the medical school curriculum.

The Medical School Curriculum

In a seminal article on medical education, a critical distinction was noted between the "formal" curriculum―the courses that actually appear in the official catalogue, and the "hidden" curriculum, which is predominantly concerned not with the imparting of knowledge and skills but, rather, with "replicating the culture of medicine."13 Traditionally, the first two years of medical school are taught by basic science faculty in the form of classroom lectures on such subjects as anatomy, pathology, physiology, biochemistry, pharmacology, and microbiology. While there has been some reform of the "preclinical" years to provide students with limited opportunities to encounter the actual settings in which patient care takes place, these remain a very small portion of the first two years of medical school. Consequently, these years are dominated by the formal curriculum. In stark contrast, year three of medical school consists of a number of required clerkships of roughly eight weeks. Those clerkships are usually medicine, surgery, pediatrics, primary care, obstetrics and gynecology, and psychiatry. In the clerkships, students work with residents, attending physicians, nurses, and other healthcare professionals in the actual care of patients. The fourth year of medical school is highly flexible and intended to allow the students, within certain broad parameters, to design their own panoply of courses consistent with the nature of the residency program they expect to enter following graduation. For students who expect to enter residencies that are not among the specialties that comprise the clinical clerkships, such as anesthesiology, dermatology, and ophthalmology, the fourth year provides the time and opportunity to pursue these as clinical electives.

Clearly, the third and fourth years are when the "hidden" curriculum is an important element of the educational process. Indeed, when required ethics instruction has found its way into the first two years of medical school, the faculty who teach it often lament that what the students learned about ethics in the formal curriculum of those years is largely undone by the oppositional forces of the hidden curriculum in the clinical years.14 If the primary pedagogical emphasis of the first two years of medical school is the curriculum of the basic sciences, the parallel emphasis in the last two years is clinical medicine, i.e., learning to perform like a physician. What receives little, if any, attention is how to act with professional integrity and caring. This major deficit is evidence of a compromised professional pedagogy, i.e., one that gives disproportionate attention to only two dimensions of practice―the intellectual (knowledge) and the technical (skill), virtually ignoring the third―the moral (attitudes).15 In fact, the data suggest that in their clinical years students are not merely deprived of meaningful opportunities to consider the ethical dimensions of what they are learning on the wards, they are routinely exposed or subjected to ethically problematic behaviors which they perceive and attach significance to, but those in positions of authority over them often do not. For example, in one study residents’ uncaring, hostile, or disrespectful attitudes toward patients were essentially ignored by attending physicians or addressed in a jocular, off-hand manner that implied toleration.16 There is no reason to presume that the attendings would have responded differently if the negative attitudes of the residents had been directed at medical students rather than patients. This phenomenon has generated an entire new genre of medical literature, "ward ethics."

Ward Ethics

Ward ethics concerns the real-life ethical dilemmas that medical students encounter on the clinical wards as physicians-in-training who are actively involved (with varying degrees of supervision) in the care of patients. The types of issues students routinely encounter, and how they elect to deal with them, takes us to the very heart of the concerns about the ethics of medical education.

One analysis of the most commonly recurring issues in ward ethics identified the following: performing procedures (without adequate knowledge, skill, or supervision), being a "team player," challenging medical routine, knowing the patient as a person, and witnessing unethical behavior.17 Clearly, the second and third issues are interrelated. If one’s objective is to be consistently viewed as a "team player," then one cannot challenge medical routine that comports with the modus operandi of the powers that be in the academic medical center. Similarly, witnessing unethical behavior, particularly if it is not infrequent, becomes an acute problem if the student has the temerity to report it. A number of recent surveys of medical students reveal that the most common response of medical students to the unethical situations they encounter is silence.18 The rationale most commonly offered for the silence has much less to do with student doubts about whether the conduct is truly unethical but, rather, with fears about reprisal for challenging medical routine or being labeled by residents or attending physicians as someone who is not a team player. Some students, however, do report that as they continue to witness what they previously considered to be unethical or unprofessional conduct, with no adverse consequences to the actor, they gradually come to question their earlier perceptions of ethical transgression. After all, if speaking in a derogatory fashion about some patients or colleagues without justification or provocation, or refusing to respect patient wishes and values were truly a violation of ethical and professional standards of conduct, surely someone other than a medical student would recognize that fact and take appropriate remedial measures.

Students find ludicrous in the extreme the suggestion that they have any ethical responsibility to speak up, as has been suggested in at least one article on the subject.19 They express amazement and disbelief at any assertion that medical students should be expected to engage in acts of moral courage in addition to acts of intellectual brilliance, technical skill, or sheer physical endurance. One astute observer of medical education has identified the singular paradox that while patients and society expect physicians to be autonomous, alert, creative, and decisive, they spend most of their professional education demonstrating docility by passing on the common rule for surviving the clinical years: "Don’t ask questions."20 The paradox is actually even more remarkable, since medicine is supposed to be one of the learned professions. How one becomes learned (as opposed to simply knowledgeable) without voicing questions in the presence of one’s teachers and fellow students defies understanding.

It may not be simply cynicism that the contemporary system of medical education is breeding but depression and disillusionment as well. A recent article reported that while students entering medical school are no more prone to depression than other persons their age, medical students are more prone to depression than their non-medical peers, and the prevalence increases disproportionately during medical school.21 At one very prominent medical school 25 percent of the first and second-year students were considered to be depressed.22 One fourth-year medical student who sought mental health treatment noted that her depression seemed to start in the third year, lamenting: "I don’t like what I’m seeing in the hospital; that’s not how I want to practice medicine."23

At this point we should return to the fundamental question posed early in this paper: How could any rational person, not to mention an entire profession, ever expect to fashion humane, compassionate, caring physicians in an environment characterized by harshness, rigidity, and cynicism? The most plausible answer, of course, is that one could not. But perhaps that is no longer the goal of medical education, if, indeed, it ever was.

Today’s academic medical center is buffeted by unprecedented market forces. Patient care must comport with the demands of the business of healthcare delivery, including diminished reimbursement for patient care, competition by the other hospitals and clinics in the area that are not expected to train the next generation of physicians or to care for this generation of the medically indigent and uninsured patients. Medical faculty, too, must meet many more expectations than their competing colleagues in the community. Not only must they provide and supervise patient care, but they must also pursue highly competitive federal research grants and take responsibility for the formal curriculum of the medical school. Perhaps these multiple pressures simply make a humane, caring, nurturing, and supporting learning environment, particularly on the clinical wards where third and fourth-year medical students spend most of their time, a completely unreasonable expectation. This may be why third-year students in particular report that it is not unusual to be treated by some faculty, attending physicians, and senior residents as though they are simply in the way, making the primary task of delivering patient care more difficult than it would otherwise need to be.

Despite such countervailing practical considerations, the accreditation bodies for undergraduate and graduate medical education have placed increasing emphasis upon the responsibility of academic medical centers to cultivate professionalism. Professionalism in this context is described as including the following humanistic values: honesty and integrity; caring and compassion; altruism and empathy; respect for patients, peers, and other healthcare professionals; and adherence to high ethical and moral standards. The delineation of such standards of professionalism include no exceptions for the financial or practical exigencies facing academic medical centers, their faculty, or their administrators.

Professionalism, one would hope, encompasses the role of medical educator. The report of the Association of American Medical Colleges Medical Schools Objectives Project published in 1998 listed as the first among the stated goals and objectives of medical school education the cultivation of altruism. Among the elements of altruism the report identified were:

- Knowledge of the theories and principles governing ethical decision making.

- Compassionate treatment of patients, and respect for their privacy and dignity.

- Honesty and integrity in all interactions with patients’ families and colleagues.

- Commitment to advocate at all times the interests of one’s patients over one’s own interests.24

Similar admonitions have been provided by the accrediting organization for graduate medical education. In 2002, the Accreditation Council for Graduate Medical Education (ACGME) promulgated six general competencies for graduate medical education. One of these was professionalism, which was stated to include the following:

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to demonstrate:

1. respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest…

2. a commitment to ethical principles…

3. sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.25

Clearly, both undergraduate and graduate medical education programs have been recently charged with a responsibility to ensure that ethics, values, and professionalism are infused throughout their curricula. However, if the reports of widespread mistreatment of medical students are reasonably accurate, then many institutions are out of compliance with AAMC and ACGME standards. At the very least, these faculty members are not consistently practicing the professional ethos they are charged with teaching.

Perhaps in recognition of this fact, increasing numbers of institutions have at last begun to promulgate policies and procedures designed to address the very problems that we have considered. The recent proliferation of these policies indicates: 1) the problem is persistent and pervasive; 2) such conduct on the part of medical educators is not deemed to be a necessary or even acceptable aspect of training; and 3) medical schools appear to be serious about addressing the problem.

Remedial Measures: Medical Student/Resident Mistreatment Policies

One such policy, at UCLA, begins by setting out a standard of conduct based upon the premise that optimal learning can take place only in an environment in which teachers and students treat each other with respect and that is free of "harassment, intimidation, exploitation, and abuse, and one in which feedback regarding performance can be shared openly without concern for ridicule or reprisal." Among the examples of mistreatment listed in the policy are:

- Criticism or other actions that can reasonably be interpreted as demeaning or humiliating.

- Assigning duties as punishment rather than education.

- Asking students to carry out personal chores.

- Intentional physical contact such as pushing, shoving, slapping, hitting, tripping, throwing objects at, or aggressive violation of personal space. 26

The policy calls for the establishment of a Student Mistreatment Committee (SMC) comprised of three faculty, one third and one fourth-year medical student, a nurse, a chief resident, a graduate student, and a member of the Gender and Power Abuse Committee. The committee will process complaints when informal efforts to resolve the situation have been exhausted. Following investigation by a subcommittee, the SMC makes findings that are forwarded to the Executive Associate Dean for a final decision. The policy also calls for disciplinary action for malicious accusations or retaliation against those reporting mistreatment. Since promulgation of the policy, complaints by students have been handled informally through the campus ombudsperson and clinical program directors. There has not, as yet, been a need to resort to the formal procedures set forth in the policy. Each year students are surveyed about mistreatment by the Dean’s office.

Within the last year, the University of California–Davis School of Medicine has adopted a Professionalism Policy that establishes an Optimal Learning Environment Committee (OLEC) to respond to complaints of mistreatment made by medical students or residents. The committee is to consist of a faculty chair, three additional faculty members (one basic science, one medical specialty, one surgical specialty), two fourth-year medical students, two chief residents (one from a medical and one from a surgical specialty), one graduate student, and one clinically active RN.

What many of these policies do not address are the "Ward Ethics" issues that do not technically constitute student mistreatment but, nevertheless, tend to breed cynicism in medical students. These are the negative behaviors by those in mentoring or role-modeling relationships to students, such as speaking disparagingly about patients or making them the objects of derision.

Conclusion

Returning to the overarching question with which we began this analysis: "How could any rational person, not to mention an entire profession, ever expect to fashion humane, compassionate, and caring physicians in an educational environment characterized by harshness, rigidity, and cynicism?" The answer is that no one could. In order to explain the pervasiveness of abusive behaviors by some of those in positions of responsibility, we need to consider as the primary culprit the unreflective repetition of routines and practices that even at their inception had neither moral nor pragmatic justification. There is an exquisite irony in the fact that in this era of high tech, evidenced-based medicine, these anachronistic and ethically flawed approaches of utilizing intimidation and humiliation as a means of training and enculturating medical students persist although devoid of any justification other than the ritualistic mantra that "we have always done it this way."

Going forward, medical school policies prohibiting abusive behaviors toward students must become a vital part of the ethos of the institution and of the profession, and not mere window dressing intended to placate credentialing bodies. If medical students are admonished to demonstrate moral courage by reporting abusive behaviors by faculty or residents that they experience or witness, then the institutions and their leaders must in turn demonstrate the moral courage involved in rehabilitating or rooting out those faculty who fail or refuse to fulfill these standards of professionalism, no matter how longstanding their tenure in the institution or substantial their contribution to clinical revenue or research productivity.

Endnotes

1. Richard Selzer. Letter from a Young Doctor." In Ward Ethics—Dilemmas for Medical Students and Doctors in Training, edited by Thomasine K. Kushner and David C. Thomasma (New York: Cambridge University Press, 2001).

2. RM Sade, GA Fleming, RG Ross. A Survey on the "Premedical Syndrome," J Med Educ, 59 (1984): 386-91.

3. RH Coombs and MJ Paulson. "Is Premedical Education Dehumanizing? A Literature Review," J Med Humanities, 11 (1990): 13-22.

4. The quantity of basic science course work in the first two years of medical school has been the subject of recent criticism. An example is T. V. Rajan, "Making Medical Education Relevant," Chronicle of Higher Education (January 13, 2006): B20.

5. DC Baldwin, et al. "Student Perceptions of Mistreatment and Harrassment During Medical School: A Survey of Ten United States Schools," West J Med, 155 (1991): 140-45; WM Satterwhite III, RC Satterwhite, CE Enarson. "Medical Students’ Perceptions of Unethical Conduct at One Medical School," Academic Medicine, 73 (1998): 529-31; SR Daugherty, DC Baldwin, BD Rowley. "Learning, Satisfaction, and Mistreatment During Medical Internship: A National Survey of Working Conditions," JAMA, 279 (1998): 1194-99.

6. Leon R. Kass. "Practicing Ethics: Where’s the Action?" Hastings Center Report, 20 (1990): 5-12.

7. Lee S. Shulman. "Signature Pedagogies in the Professions," Daedalus, 134 (2005): 52-59.

8. Harry T. Edwards. "The Growing Disjunction between Legal Education and the Legal Professon," Michigan Law Review, 91 (1992): 34; Alex M. Johnson, Jr. "Think Like a Lawyer, Work Like a Machine: The Disonance between Law School and Law Practice," S. Cal. L. Rev., 1231 (1991).

9. Sherwin Nuland. How We Die (New York: Alfred A. Knopf, 1994), 253.

10. Nuland, 248-49.

11. Erich J. Cassell. "The Changing Concept of the Ideal Physician," Daedalus, 115 (1986): 185-208, 189.

12. Ibid., 206.

13. FW Hafferty and R Franks. "The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education," Academic Medicine, 11 (1994): 861-71.

14. Jack Coulehan and Peter C. Williams. "Conflicting Professional Values in Medical Education," Cambridge Quarterly of Healthcare Ethics, 12 (2003): 7-20.

15. Shulman, note 6, p. 52.

16. JH Burack, et al. "Teaching Compassion: Attendings’ Responses to Problematic Behavior," Journal of General Internal Medicine, 11 (1996): 113.

17. DA Christakis and C Feudtner. "Ethics in a Short White Coat: The Ethical Dilemmas that Medical Students Confront," Academic Medicine, 68 (1993): 249-54.

18. Catherine V. Caldicott and Katherine Faber-Langendoen. "Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third Year Medical Students," Academic Medicine, 80 (2005): 866-73; Robert C. Satterwhite, William M. Satterwhite III, Cam Enarson. "An Ethical Paradox: The Effect of Unethical Conduct on Medical Students’ Values," Journal of Medical Ethics, 26 (2000): 462-65.

19. James Dwyer. "Primum Non Tacere: An Ethics of Speaking Up," Hastings Center Report, 24 (1994): 13-18.

20. Howard F. Stein. American Medicine As Culture (Boulder, CO: Westview Press 1990), 185-86.

21. Julie M. Rosenthal and Susan Okie. "White Coat, Mood Indigo—Depression in Medical School," JAMA, 350 (2005): 1085-88.

22. JL Givens and J. Tija. "Depressed Medical Students’ Use of Mental Health Services and Barriers to Use," Academic Medicine, 77 (2002): 918-21.

23. Rosenthal and Okie, note 19, p. 1087.

24. Association of American Medical Colleges, Learning Objectives for Medical Student Education—Guidelines for Medical Schools, January 1998.

25. Accreditation Council on Graduate Medical Education, Outcomes Project, http://www.acgme.org/outcome/comp/compFull.asp.

26. David Geffen School of Medicine at UCLA, Policy for Prevention of Student Mistreatment (1/26/2005).

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Fall 2006 Volume 06, Number 1

Fall 2006
Volume 06, Number 1