Correspondence

Becoming a Doctor

N Engl J Med 1994; 330:720March 10, 1994

Article

To the Editor:

As fourth-year medical students at the University of Pennsylvania School of Medicine, we led discussions of ethical issues with third-year medical students. These discussions included consideration of the ethical issues that the students faced as clinical clerks1. The issues were similar to those noted by Branch et al. (Oct. 7 issue)2 and by others3. We agree, as Branch et al. emphasized, that the third year of medical school is often a time of critical incidents in the lives of students. There are additional issues, however, that should be considered.

An understanding of the genesis and implications of the problems encountered by medical students requires a deeper analysis than the dialectical model of empathy and acculturation4 advanced by Branch et al. These aspects of student life and development are too broad and obscure many difficult problems that medical students confront. In particular, the model neglects students' struggle with the interpersonal dynamics of power and authority that permeate the hierarchical structure of medical teams1,5.

Authority and power are thorny aspects of hospital practice. Although they are usually used judiciously and to the benefit of patients and students, they can have untoward effects. Many of the examples cited by Branch et al. involved students who had witnessed their superiors' rude or even unethical behavior. A student's initial bewilderment when witnessing such behavior may become blind acceptance alarmingly quickly. By calling this process “acculturation,” we may unintentionally gloss over the abusive or coercive aspects of medical education and care. Many established physicians even consider such critical incidents rites of passage in the culture of medical practice. The process of becoming a doctor seems to be traumatic and hurtful for too many students,6 and it will remain so if the medical community shies away from the problems posed by authority.

Dimitri A. Christakis, M.D.
Children's Hospital and Medical Center, Seattle, WA 98104

Chris Feudtner
University of Pennsylvania School of Medicine, Philadelphia, PA 19104

6 References

1. 1

   Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993;68:249-254
   CrossRef | Web of Science | Medline

2. 2

   Branch W, Pels RJ, Lawrence RS, Arky R. Becoming a doctor -- critical-incident reports from third-year medical students. N Engl J Med 1993;329:1130-1132
   Full Text | Web of Science | Medline

3. 3

   Bickel J. Medical students' professional ethics: defining the problems and developing resources. Acad Med 1991;66:726-729
   CrossRef | Web of Science | Medline

4. 4

   Lief H, Fox R. Training for `detached concern' in medical students. In: Lief HI, Lief VF, Lief NR, eds. The psychological basis of medical practice. New York: Harper & Row, 1963:12-35.
   

5. 5

   Feudtner C, Christakis DA. Making the rounds: the ethical development of medical students in the context of clinical rotations. Hastings Cent Rep (in press).
   

6. 6

   Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA 1990;263:527-532
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The negative influence of authority figures certainly did emerge in some of the critical-incident reports. We wanted to show how difficult a process acculturation is when it includes feeling forced to accommodate oneself to behavior that may compromise one's ethical values. Our paper should contribute to the discussion of this issue, which is raised in other ways -- for example, by the unearthing of medical student abuse1-3. We found few cases of outright abuse. The stories in our paper illustrate the equally profound personal and ethical struggles of deeply concerned students who are not being abused. Faculty members address these issues, including the misuse of authority, in ways that are meant to support the students. In a few cases we have provided feedback, through the proper channels, to teachers and others when requested to do so by students who witnessed unusually egregious instances of misconduct. Providing such feedback was our responsibility and is also the responsibility of others involved in medical education.

We do not think that medical education is mostly a negative experience. Rather, we see a need to be aware of our shortcomings and continuously improve ourselves and our profession, which ought to set a high standard of ethical behavior in society.

William T. Branch, M.D.
Richard J. Pels, M.D.
Harvard Medical School, Boston, MA 02115

Robert S. Lawrence, M.D.
The Rockefeller Foundation, New York, NY 10036

Ronald Arky, M.D.
Harvard Medical School, Boston, MA 02115

3 References

1. 1

   Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA 1990;263:527-532
   CrossRef | Web of Science | Medline

2. 2

   Sheehan KH, Sheehan DV, White K, Leibowitz A, DeWitt C, Baldwin DC Jr. A pilot study of medical student “abuse”: student perceptions of mistreatment and misconduct in medical school. JAMA 1990;263:533-537
   CrossRef | Web of Science | Medline

3. 3

   Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA 1992;267:692-694
   CrossRef | Web of Science | Medline