commander, mentored by another doctor, and he participated in the selections without further incident.
The doctor […] if not living in a moral situation […] where limits are very clear […] is very dangerous.
– Auschwitz survivor
In light of these and other dark pages in medical history, there is an obligation for physicians to constantly reconsider their practices. Although standard medical training today is in no way comparable to the practices of doctors at Auschwitz, some of the psychological mechanisms Lifton described are disturbingly familiar to medical students.
In their essay on professionalism, then-medical students Andrew Brainard and Heather Brislen paint the unsettling picture that most students “seem to adopt an implicit set of rules that place hospital etiquette, adherence to academic hierarchy, and subservience to authority above patient centered virtues.”
“Students become ‘professional’ and ‘ethical’ chameleons because it is the only way to navigate the minefield of an unprofessional medical school or hospital culture,”24 they write. Students are molded into obedience, and learn that they get better grades in professionalism, when compromising their ethical standards and “mimicking the unprofessional behavior of their educators.”
Many students witness unethical acts for which the physicians in question are not held accountable, as they are protected by the hierarchy of authority. Because reporting or questioning these acts is regarded as disruptive and therefore unprofessional behavior, many students will very quickly learn to simply conform. As a result students feel “mute” in morally distressing situations and complicit as bystanders to their superiors’ actions, which causes them to feel powerless and “trapped in a hierarchy.”
This is a way for students to distance themselves from their inaction or immoral actions by shifting the blame to the system or supervisor and explaining to themselves that they have no choice.
It may very well be that, in order to adapt, students feel inclined to double and form a “medical self” that will act in the way that is expected of them. However, as Lifton and Rank describe, the risk is that this medical self may ultimately replace the prior self.
The consequences of this cycle of hierarchical and social pressure, moral compromise, and consequent habituation are many. Most importantly, this can lead to an erosion in professional and academic integrity, as exhibited in a study showing that first year students were more likely than more advanced students to identify case scenarios describing academic dishonesty as being unacceptable.
Furthermore, a larger proportion of the more advanced students indicated that they had or would engage in such dishonest behavior. The erosion of professional integrity was also evident in a survey that asked medical students in different years of their education about their experience with and attitudes towards cheating. In their first year, 97 to 100% of students said they expected not to cheat in medical school, but by their fourth year, up to a quarter of all students reported having cheated in activities directly related to patient care. These actions, such as lying about having ordered a test, reporting findings elicited by others, and recording tasks not performed, were often motivated by fear or “the pressure to appear as if [one] knew everything.” One respondent noted that she was actually advised by a resident that she “would come off better if [she] lied a little.”
If upcoming physicians have to create medical doubles for themselves to “survive medical school,” then it’s conceivable that, by the time students become residents, their medical selves will have replaced their prior selves and will teach or oblige new students to double as well. The “see one, do one, teach one” approach in medicine only exaggerates this phenomenon through groupthink. Brainard and Brislen argued that “students’ professionalism has been questioned when they disagree with a team.” Or, as one student was told by his clerkship director: “the most important professional virtue is getting along with your superiors.”
Perceived powerlessness, doubling, and “groupthink” seem to be an essential part of a hidden curriculum that focuses on maintaining the hierarchy of authority. Physicians need to reexamine the structural mechanisms in medical training that can lead to future doctors valuing the obedience above all else, and that lead to their self-perception as tiny cogs in someone else’s machine.
We might simply feel bad, and let it go at that, when patients are mistreated because of undue obedience on the part of health care personnel, if it weren’t for other findings of Milgram’s research. For not everybody obeyed […] Appropriate disobedience can be taught.
— Eric J. Cassell
The issues of mistreatment of medical students and misuse of power by physicians have been known for decades. Yet policies and educational courses have failed to eradicate this structural mistreatment. Researchers have suggested that the hidden curriculum might be inhibiting change.
Interventions such as courses on how to handle sexual harassment, mistreatment, and unfair feedback do not address social pressures and institutional forces that lead to misuse of power. By teaching students how to function in this broken system, educators confirm the status quo and encourage students to adapt and double in order to create a more resilient medical self. In some of these classes, students will be told that they can do better once they’ve become physicians, which creates the unfair expectation that individual students alone should initiate change of such institutional problems and incites feelings of guilt when students can’t live up to these expectations. Brainard and Brislen conclude that “the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged” and leaves students “feeling persecuted, unfairly judged, and genuinely and tragically confused.”
Talk about power
Instead of teaching students how to endure maltreatment during their internships, education should focus on how to responsibly handle the power that comes with being a physician. Throughout their careers, most students will come to accept the status quo, partly because they adjust but most importantly because the higher they climb in the hierarchy, the more privileges they will experience as result. Because the hidden curriculum teaches students not to speak up, physicians are hardly ever criticized.
One of the ways to address this is to have students grade their educators. This would serve the dual purpose of creating a system to put a check on power while also rewarding positive role models.
Second, the evaluation system used to assess student performance can also be an important factor in the balance of power. Compared to a pass-fail approach, an A-F grading scheme promotes peer competition and anxiety rather than collaborative learning Students have cited grades as one of the reasons to compromise their ethical standards. Pass-fail evaluations might help students feel less anxious about grades and more secure in their moral perspectives. In this system, failing a student would have to be an extraordinary measure only taken in the case of irrefutable misbehavior. This would therefore protect students from being subjectively punished with low grades for not “mimicking the unprofessional behavior of their educators.”
A third approach was taken by Yale School of Medicine almost two decades ago.
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