Reprogramming the Ethics of Med Students

A few days ago, the Mayo Clinic released the results of a study on the relationship between burnout and ethics among students at seven medical schools across the country. The study's first result, which was not surprising, was that more than half of the students reported burnout. More surprising was its finding that 40% of 3rd and 4th year students admitted to "some form of unprofessional conduct in relation to patient care," such as saying they'd done an exam when, in fact, they hadn't.

Also surprising was the study's finding that only 14% of those students had an opinion about "appropriate interactions between physicians and pharmaceutical companies." How could 86% of medical students not even have an opinion on such a hot subject?

The Mayo report authors said the results indicated that "some elements in the learning process" may foster dishonesty, and that burnout seemed to be a threat to future physicians' "altruism, professionalism and commitment to serve society." But some medical school educators think it's more complicated than that.

Dr. Stephen Klasko is the CEO of USF Health and Dean of the College of Medicine at the University of South Florida, in Tampa. And he believes the Mayo Clinic results reflect problems with both the emotional intelligence of the typical medical student, as well as a phenomenon the American Association of Medical Colleges calls the "hidden curriculum" of physician training.

What is the "hidden curriculum"? As Klasko describes it, "in the first two years of medical school, we teach ethics and the right thing to do. But then the students go into a hospital setting, and who they're learning from is a 50-year-old doc at midnight, who comes from the old, autonomous model of medicine, who tells them to do it another way." Klasko gives the example of a Georgetown University study in which medical students were asked to give a sleeping woman in a hospital bed a pelvic exam, with the attending physician telling them it was okay, even though the patient was asleep and hadn't given her consent. Ninety-five percent of the first-year students wouldn't do the exam, even though they were told it needed to be done. Only 33% of the fourth-year students refused to do the exam.

"Part of the stress the students feel is the disconnect between what's taught in the classroom and what's taught by the docs. Although to be fair to the old school docs," Klasko says, noting that he, himself, is 56, "it's what we had to do to survive in the old system." That mixed-message confusion also extends to other ethical issues in medicine--which Klasko thinks explains the 86% of students in the Mayo study who had no opinion on physican-pharmaceutical company relationships.

"The better question to ask wouldn't have 'what's your opinion,' but 'are you confused about what's ethical when it comes to physician-pharmaceutical company relationships," Klasko says. "Until recently, those relationships were considered okay. Now, in med school, there's a lot of discussion about it, and pharmaceutical companies can't do lunches, for example. But then our students are learning from people in private practice who tell them it's okay. So they're left not knowing what to think."

So what's to be done about all that confusion? It's a complex problem, but Klasko sees three distinct changes that need to be made. "We need to choose a different kind of medical student, teach them differently, and teach the teachers differently," he says.

First, he says, "we might be picking the wrong people for what is increasingly an ambiguous and team-based job. We pick students based on their science GPA, their MCATs, and their organic chemistry grade, and then we're amazed when they're not empathetic and creative. We don't look at their emotional intelligence."

What's more, Klasko notes that "the way we train those students now, they feel as if they've joined a cult. And that cult is based on four distinct biases: an autonomy bias, a hierarchical bias, a competitive bias, and a non-creativity bias. Now, those elements work in a clinical application, but they can leave students feeling isolated, which leads to burnout. They also don't help students sort through the more ambiguous areas of ethics, collaboration, communication, or coping with a changing profession. So we need to start selecting kids with the emotional intelligence not to join that cult."

Then, Klasko says, med schools need to do a better job of changing the culture among medical school faculty. "Among a typical medical school staff, there are probably 20% who really get this stuff," he says. "And there are 15% who will never get it. The 65% in the middle are what we call the 'silent majority.' They're listening, and potentially open to change. But when we looked at how medical school deans were spending their time, we found, pretty consistently, that deans spent about 40% of their time with the staff who 'got it," because they resonated with them. And they spent about 40% of their time trying to convert those who are never going to get it. They spent the least amount of time with the group in the middle who might change; who might really allow them to change the culture. And if we could change the culture, we could eliminate the hidden curriculum."

Tall order, but Klasko notes that USF has changed its selection criteria for incoming students, and now trains its med students with the nursing school students, to help the future physicians learn to work as a team. Is USF an outlier? Klasko doesn't think so. "There's a movement out there," he says. Only a few are making it a priority right now, but more are getting it--especially with the coming changes in the health care system."