Are Ethics Getting Shortchanged In Student And Residency Training?
Recently, there was discussion on Podiatry Management online regarding the professional conduct of students and residents. The discussion was centered on what was perceived to have been “unprofessional” conduct, and a discussion of the evaluation of so-called “non-cognitive behaviors” ensued.
Studies have demonstrated that unethical and unprofessional behaviors are learned during training. Students and residents observe rather quickly that accountability for ethical misconduct is frequently lacking in medicine, and that a strong position of self-judgment as well as autonomy exists within medicine. As a result, insularity and isolation are perceived as acceptable, and there is disparagement of any “outsiders” who offer judgment regarding the actions of medical professionals.
In their study, Novack and colleagues noted that the majority of physicians surveyed: were willing to misrepresent a screening test in order to secure an insurance payment; would offer misleading information about a mistake, which led to death; or admitted a willingness to engage in deception if it benefitted the patient.1
In another study, Feudtner and co-workers noted that 58 percent of medical students admitted doing something unethical, 52 percent admitted to willfully misleading a patient, 61 percent stated that they have observed unpunished unethical behavior, and 54 percent of students stated that they “felt like an accomplice” to unethical behavior. According to the study, 67 percent of students and residents felt guilty at their lack of ethical behavior during training, and 62 percent felt that their ethical principles had been lost or eroded.2
Students and residents typically do not act on unethical behavior due to fear of poor evaluation or “not fitting in” with the team.
Recently, two residents and a student doctor asked to meet with me about their concerns. They had all been assigned to rotation in the office of a “prominent” doctor. All related the same story. They stated that every heel pain patient underwent ultrasound examination and the patients were told they had a disease too far advanced for non-operative care. All patients were subjected to endoscopic plantar fasciotomy (EPF), which was supplemented by radiofrequency coblation. Then patients were placed in a CAM walker and subsequently transitioned into orthotics.
They reported this to their school officials and were informed that they were there to learn and not to make judgments. They asked me one question: “Is this what we will have to do to make a living?”
1. Novack DH, Detering BJ, Arnold R, Forrow L, Ladinsky M, Pezzulo JC. Physicians’ Attitudes Toward Using Deception to Resolve Difficult Ethical Problems. JAMA.1989;261(20): 2980-5.
2. Feudtner C, Christakis DA, Christakis NA. Do Clinical Clerks Suffer Ethical Erosion? Students’ Preceptions of Their Ethical Environment and Personal Development. Academic Med. 1994;69(8):670-9.