Weeding Out Medical Student Ethical Misfits: Who is Responsible to Do That?
I was stimulated by the theworld.com’s link to the UK Guardian’s article about testing medical students for how well they have learned ethics and if they failed the test they should be dropped from medical school and not given the M.D. degree. I put the issue up to the ethicists on a bioethics listserv and interestingly two points of view were presented in response.
One view was the argument that the degree of medicine was nothing more than representing a technical achievement and medical schools should not be responsible for weeding out “ethical misfits or even miscreants”:
“ I propose that this task should be left to
licensing boards (just as lawyers have to pass character tests in
addition to the bar). If someone of dubious ethical constitution wants
to go out and *learn* about medicine, I don't see any reason why anyone
should object. Now, if he wants to *practice* medicine, then there is a
problem. More generally, I view a medical degree as a ‘certification of
technical merit’ (to use a phrase the DoD has been using) and object to
their being any moral prerequisites for the degree (note that the
requirement for courses in medical and legal ethics are requirements for
study, not for character).”
The other view:
“I believe that professional schools such as medical and nursing schools
have a strong, pro-active duty to "weed out ethical miscreants". There
are several reasons for this:
1) It is unreasonable to expect that this could be done at licensing. As
teachers we are in the best position (perhaps the ONLY position) to
observe behaviors that are inappropriate. There is absolutely *no*
mechanism by which a sociopath could be identified at the point of
licensing but many points during their education process.
2) The public funds a significant portion of professional education and
clearly expects that we will produce not just competent clinicians but
also decent ones. There is a very clear public expectation that a student
who exhibits truly egregious behavior will be 'culled' from the ranks.
Examples of behavior that ought to result in dismissal include patterns of
behavior (not necessarily single instances) of lying, covering up errors,
harsh treatment of patients, inappropriate interactions with colleagues
(such as yelling, demeaning comments), etc.
3) We have a duty to begin mentoring students in the fiduciary nature of
the health care relationship, and to live by our own teachings.
Professions are self-regulating. We are granted the right to practice our
professions with the agreement that *we* will insure that our clinicians
are competent. To ignore egregious behavior in students is to ignore our
professional duty to police ourselves.”
I would very much like to read comments from my visitors (including medical students) to this blog as to what they consider are the responsibilities of medical schools to society with regard to the ethical behavior and ethical knowledge of the student who may be receiving the degree of Doctor of Medicine. ..Maurice.
posted by Maurice Bernstein, M.D. @ 3:33:00 PM
9 comments
9 Comments:
One would hope that those with questionable ethics are weeded out in the medical school application process. As a current student, I can say from experience that this doesn't always happen. I think part of the problem is medical school admissions criteria; there is such a focus on test scores above everything else, that people will do anything for the grade, just to get in. Character issues often do come up in the interview, letters of recommendation or in a personal statement, and I'm sure any admissions officer would be hard pressed to say that they don't consider such issues when reviewing an application.
It has been my experience that many medical schools have some sort of honor code created to address the same issues you bring up. Some are more enforced than others, but honor codes can certainly be used to promote ethical behavior, rather than to just punish the most egregious errors. A board made up of students and faculty can be used to handle complaints. Again, the culture of the medical school is a factor--I'd imagine that there are many more instances of unethical behavior at more cutthroat schools.
I think that more work should be done after graduation from medical school. The creation of a physician honor code could be used as a measure of self-regulation (without involvement of licencing boards). Obviously an enforced honor code at this level would be more difficult to implement.
I find it hard to believe that leaving this issue up to the licensing boards would be at all sucessful. It is generally easy enough to just give the "right" answers in a character test. The true test of ethical behavior can only come by observing what someone does in different types of experiences.
Mudfud, thanks for your comments based on your experience as a student. I agree that if medical schools should be responsible for screening and removing students who pose anticipated significant behavioral problems to later practice, it should really begin at the medical school admission level. Never having been on an admissions committee, I don't know how many students are actually discovered to be ethical misfits and are turned away.
Once these students get into med school, there is the legal burden to the school, despite behavioral documentation, regarding suits initiated by the student who is told to leave. I feel that the schools would have greater legal clout to search out "bad" students and to get them out of school if there would be state legislative rules, regulations and laws defining this responsibility of the medical schools. Otherwise, it may be less painful for the schools to graduate the student and hope others, such as the licensing boards will do the "weeding out". ..Maurice.
On first reading, I liked the idea of medical schools bearing some responsibility for weeding out unethical students. As I thought about it, though, I have concerns about how "ethics" will be defined. Will prolife physicians be weeded out b/c they aren't willing to perform abortions? Will individuals with a natural bent be weeded out b/c others consider it unethical to, say, back up midwives for birth?
Self policing, though, is obviously not working well in some cases at all. More openness to the possibility of both unethical and incompetent physicians would help, but doctors feel sometimes seem compelled to protect their own to frightening extremes.
As an aside, I'm a frequent responder to your blog, and it probably seems as though I hate doctors. I really like them, but I think the medical system (both educational and practical) in the U.S. needs a major overhaul. Thank you for bringing some issues to the public eye that often go unseen.
5in9years
Don't medical professional have an ethical responsibility to police their own membership? Isn't this part of what being a professional means?
If there is such a responsibility, then it would require action during medical education, at licensing time, and afterwards—whenever occasions warrant.
I think the medical education system is where "unethical" students need to be weeded out. It's in education that we inculcate values, whether we mean to or not. However...
a) it's very, very hard to require "professional" and "ethical" behaviour from students if they are frequently and repeatedly exposed to their superiors behaving in ways which are not. Residents and attendings need to be held accountable for their behaviour as well, otherwise there's a laughable double standard there. Don't send the message that you "need to behave" until you are an attending.
b) schools need to guard against the temptation to start labeling all "problem behaviour" as "unethical" or "unprofessional". A student who may be exercising free speech rights or standing up for themselves in a manner which is generally acceptable in most arenas of education shouldn't be shunted into the "unprofessional behaviour" system solely because there's an administrative disagreement with the student. It's a very slippery slope from requiring "ethical and professional" behaviour to changing it to a tool for compelling student obedience.
I agree that any action taken at the education level does need to be done with care--especially given the possible legal implications. And, while I'm certainly not up to speed with the law, I believe the schools can protect themselves somewhat by having students sign a carefully constructed contract before the start of school which outlines what types of behaviors (e.g. cheating) are prohibited, and what the consequences of specific infractions would be.
Now, you do have the problem of students who are just outside the grey area of what "professional" or "ethical" behavior is, as well as the issues that Dipesh brings up. There are often mitigating circumstances in cases of "unethical behavior." What if a student lied to protect themselves from uncovering something personal that might harm them further in their career (family issues, homosexuality, mental illness, etc.)? Where is the line between harsh treatment of patients and poor bedside manner or just a really bad day? What if inappropriate interactions with colleagues are due to an undiagnosed illness, or untreated substance abuse (which is later treated)?
Obviously, there is no perfect solution here. There will always be people with abrasive personalities, people who will lie and cheat to get ahead. If the hierarchy of medicine wasn't so rigid, perhaps students and doctors alike would be more willing to actually self-regulate the profession, instead of being afraid to report or confront our colleagues.
Dave,Dipesh and Mudfud all show concern about the professional responsibility of physicians to watch over the behavior of their mature colleagues since poor ethical behavior can produce poor role models for the students along with physical or emotional harm to patients and a black eye for the medical profession. But I can tell you, as a hospital ethics committee member, I can see that most physicians are shy to tattle on their fellow physicians behavior unless drug, alcohol or mental illness is suspected. It is almost like they are defending a physician's "right" of non-interference when it comes to "different approaches in patient communication or care". This latter expression is probably the cover for what we might call "ethical misfits". Tough problem. ..Maurice.
Maurice, I'm well aware of the reluctance you mention—I've frequently discussed it with my friends who are physicians. But I've also heard physicians bitterly complain about their profession being policed by non-physicians i.e. laymen.
Like it or not physicians will be policed by themselves or by non-physicians or both. Stepping up to the plate and accepting what are, in fact, their professional obligations is IMO more likely to result in a satisfactory outcome.
In the introductory line of your post, Dr Bernstein, please give credit where credit is due. It is not "theworld" but my weblog, Follow Me Here, http://gelwan.com/followme.html to which you link. Thank you.
-- Eliot Gelwan MD
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