Bioethical Inquiry (2012) 9:135–147 DOI 10.1007/s11673-012-9365-z

ORIGINAL RESEARCH

Competing Duties Medical Educators, Underperforming Students, and Social Accountability Thalia Arawi & Philip M. Rosoff

Received: 10 October 2011 / Accepted: 9 November 2011 / Published online: 13 March 2012 # Springer Science+Business Media B.V. 2012

Abstract Over the last 80 years, a major goal of medical educators has been to improve the quality of applicants to medical school and, hence, the resulting doctors. To do this, academic standards have been progressively strengthened. The Medical College Admission Test (MCAT) in the United States and the undergraduate science grade point average (GPA) have long been correlated with success in medical school, and graduation rates have been close to 100 percent for many years. Recent studies have noted that some doctors having difficulties in practice were found to have had similar problems while in school. In this essay, we present a brief historical account of attitudes and approaches to admissions requirements, then discuss basic broad areas of accomplishment in clinical practice: academic mastery, clinical acumen, and professionalism. We then review data that suggest that lack of competency can often be detected very early in a student’s career and may or may not be immune to remediation efforts. We end with a T. Arawi Salim El-Hoss Bioethics and Professionalism Program, Faculty of Medicine, American University of Beirut, Beirut, Lebanon P. M. Rosoff (*) Trent Center for Bioethics, Humanities and History of Medicine, Departments of Pediatrics and Medicine, Duke University Medical Center, 108 Seeley G. Mudd Building, Box 3040, Durham, NC 27710, USA e-mail: [email protected]

recommendation for a course of action that upholds and fulfills the profession’s social responsibility. This will be a moral argument, defending an aggressive but equitable approach to maintaining both public accountability and trust. Keywords Medical education . Professionalism . Professional competency

Introduction and Background One of the principle responsibilities of any profession serving others is to ensure that its practitioners meet its technical and ethical standards of accomplishment. The incubators of professional excellence are its training academies, its schools: first by only permitting the most promising applicants to gain entry and then by diligently attending to the maturing capabilities and performance of the students as they steadily gain skills and acquire the excellent character and technical competency that are the center of any profession—especially one such as medicine. Schools function as gatekeepers to the world beyond their walls, validating the quality of their graduates. Only by faithfully fulfilling this vital function do they uphold their end of the social contract that permits them control of the education of new doctors and of the profession itself. Medical educators, like all those engaged in the teaching profession, have a dual and, at times, competing set of duties. On the one hand, they have a

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responsibility to the student to ensure that she is offered every possibility for achieving success consistent with her capabilities and chosen field of inquiry. On the other, faculty members are obliged to the institution and the society that warrants that school (grants it a license or accreditation, tax privileges, etc.) to ensure that graduates will honestly and forthrightly meet the standards that have been set and under which the school grants its degrees. For many students in colleges and universities, this is a fairly straightforward matter, and the harm or benefit they can cause to the public by using their training and degrees is, relatively speaking, low. However, graduates of professional schools such as engineering, medicine, dentistry, and law, have the capacity to generate great harm or great good by virtue of what they do. Society extends a good deal of unquestioned trust to practitioners in these fields that they possess the skills expected of people who have been granted the credentials to practice their craft and art. Medicine is particularly situated such that society has accorded the profession considerable leeway in regulating its practice. In return, society expects that the profession will exercise substantial oversight over its practitioners to ensure that physicians who are licensed to be doctors will be competent. Undergraduate and graduate medical educators are critical to this selfgoverning function. They are the ones who bestow the initial “seal of approval” on their diplomates, assuring hospitals and patients that graduates are prepared to become doctors. Of course, newly minted physicians come with a range of abilities, as do we all, but the expectation is that all will be at or above some arbitrarily determined bar of competency. Failing to exercise the responsibility to guarantee that assurance is a breach of the fundamental social contract that permits the medical profession to be self-regulating. Unfortunately, there are incompetent doctors. There are continually reports of the misdeeds of physicians, often breathtaking in their audacity as well as the length of time they have gone undetected or unreported by colleagues and the public. These accounts of wrongdoing include simple negligence (although maybe not so simple to those who are on the receiving end), substance abuse, financial fraud, and even major felonies. Whence do bad doctors arise? Do they bloom de novo from previously competent physicians, or are the seeds of incompetence and poor performance germinated much earlier and allowed to flourish due to an

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inability or failure to detect them and weed them out before they can do real harm? Undoubtedly, some doctors undergo crises or deterioration in their personal lives that can lead to unpredictable behavior or incompetent practices. More ominously, perhaps, others may have longstanding issues of inadequacy that have either been ignored or gone undetected by peers or teachers. The issue of medical errors and the grievous toll they take on patients highlights this concern. As discussed in the landmark Institute of Medicine report, To Err Is Human (Kohn, Corrigan, and Donaldson 2000), mistakes, both individual and institutional, lead to thousands of needless deaths each year in the United States. While most of these errors are undoubtedly not due to either malicious or unintentional negligence, some percentage is assuredly caused by doctors who are incompetent. Many changes to health care systems and medical practice have been made since this report was issued, and this has led to reductions in some types of errors; however, little headway—or, for that matter, attempt—has been made in decreasing the numbers of bad doctors. It is a trivial claim, but nonetheless true, that some people admitted to medical school should not become doctors. Medical school admissions committees are not infallible, and even the most promising of students may turn out to be poor performers when faced with the rigors of the medical curriculum and clinical practice. The research reported by several groups has suggested that, for many doctors, the problems they have both start and are probably detectable well before graduation. For example, Papadakis and colleagues have correlated problems with “professionalism” in undergraduates and residents with future reporting to medical boards (Papadakis 2004; Papadakis et al. 2008; Papadakis et al. 2004; Papadakis, Loeser, and Healy 2001; Papadakis et al. 2005; Hodgson et al. 2007; Teherani et al. 2005). Their observations have recently been replicated (Reid 2010; Yates and James 2006, 2010; Tamblyn et al. 2007). It is no doubt true that the majority of medical students or residents who have academic difficulties, including issues of questionable professionalism, will have careers with records bereft of public notice by medical licensing boards (although that may not be true of malpractice suits [Baldwin, Adamson, et al. 1996]). Nonetheless, these issues identify a group of students and young doctors who are at significantly higher risk of developing

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problems related to academic or humanistic competency. Most importantly, these data suggest that questionable behaviors and academic performance displayed early in a career (often as early as college) may not disappear with age, maturity, or even intervention. Purely academic or intellectual problems that students have in medical school may be easier to detect and potentially remediate (Gough and Hall 1975). Recognizing, uncovering, and responding to difficulties with what we now call “professionalism” is more of a challenge, and it is unclear if there have been any successful attempts to correct what may actually be, in some cases, character flaws, or if any such endeavors have been made using the most appropriate and effective approaches. For more than 70 years, American medical schools have worked assiduously to enhance their academic standards. This has resulted in increased rigor in undergraduate admissions requirements as well as the development and implementation of a mandatory test (now called the Medical College Admission Test, or MCAT) designed to weed out those students whose failure could be reliably predicted by their poor performance on this examination. This has been overwhelmingly successful in identifying academic fitness for medical school. Since the 1970s, graduation rates have consistently hovered around 98 percent, and similar completion rates have prevailed for those physicians who enter categorical postgraduate training programs. But stories of physicians acting badly or incompetently continue to appear, suggesting that there may be a discontinuity between the data on graduation rates and the reality for some students (Horton 2001; McCarthy 2000; Ramsay 2001; Arulampalam, Naylor, and Smith 2007; Glick 2001; Hiltzik 2011; Roland et al. 2011; Hodges 2006; Levine, Oshel, and Wolfe 2011; Bore et al. 2005). The crucial question thus becomes whether all of the students who graduate should be allowed to graduate. The combination of high MCAT scores and undergraduate academic success, especially the science grade point average (GPA), clearly augurs success in the preclinical years of medical school (Sanazaro and Hutchins 1963; Johnson and Hutchins 1966; Julian 2005; Callahan et al. 2010). Of course, other factors also influence accomplishment in medical school (Conger and Fitz 1963; Hauer et al. 2009; Murden et al. 2004; Johnson et al. 1998). However, it is the empirical data that are the most dependable predictors of favorable performance. Whereas most schools require demonstrations of superior academic performance for admission,

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their demand for verification of good character is more nebulous. There continue to be many attempts to obtain a comprehensive grasp of applicants’ moral temperament, including variations on interview techniques (Yen et al. 2010; Dubovsky et al. 2005; VanSusteren et al. 1999; Edwards, Johnson, and Molidor 1990; Basco et al. 2008; Roberts et al. 2008), required essays (Sternberg 2008; Ziv et al. 2008; Kaufman, Dowhan, and Dowhan 2009), letters of recommendation (Johnson et al. 1998), and even proposals to administer tests to measure moral development (Donnon, Oddone Paolucci, and Violato 2009; Prideaux et al. 2011; James et al. 2009). Of course, none of these is foolproof; therefore, the burden of detecting students who may not be fit to be doctors must necessarily be borne by medical school faculty. (Likewise, the responsibility of disciplining junior doctors falls with their supervisors.) Are medical educators and medical boards responsible for licensure of physicians as tenacious as they should be in fulfilling their fiduciary duty to society to award degrees—and, thus, the potential to obtain a license to practice—to only those individuals who have both the intellectual capability and strength and depth of character to care for and care about their future patients? A brief review of how the American medical admissions process has developed to its current state can help illuminate some of the issues and how they came about.

Some Historical Background From the United States The history of medical school admissions, practices, and graduation rates over the last century is informative. In 1910, Abraham Flexner published his report on medical education in the United States (Flexner 1910). Using language that barely concealed his contempt for the common slipshod, slack, and inconsistent pedagogical approaches to medical education, he also lambasted the minimal academic criteria for admission to even the most rigorous and scholarly of the schools. One response to his scathing indictment of American medical education was to empower the state medical licensing boards to increase the rigor of their requirements for diplomates who wished to practice. They already had the power to do so as a result of a decision of the U.S. Supreme Court in Dent v. West Virginia in 1889 and the growing power and voice of the American Medical Association (Starr 1982).

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Medical schools also began to increase the stringency of their admission requirements, initially demanding 2 years of undergraduate postsecondary education with emphasis on the sciences and finally expecting (but not yet requiring) a full baccalaureate degree. However, even with higher admissions standards and the closing of all proprietary and most sectarian schools within 20 years of Flexner’s report, graduation rates in some institutions remained a doleful 50 percent. Widespread concern about this state of affairs generated interest in developing a standardized test that could be administered to applicants in an attempt to winnow out those who were intellectually or academically unfit or unprepared to successfully complete medical school. Initially developed by F.A. Moss, the “Scholastic Aptitude Test for Medical Students” was the forerunner of the MCAT in use to this day (Moss 1930; Sanazaro and Hutchins 1963; McGaghie 2002). While undergoing a number of changes over the years, variably examining writing ability or knowledge of nonscientific information (such as world politics), the test has been notably wary of attempting to tease out details and specifics about the character of applicants. However, the “Moss Test” and its successor have been remarkably successful in their primary goal: to reduce the dropout rate, especially in the first year of medical school. As McGaghie notes, the national medical student attrition rate among freshman medical students (chiefly for academic reasons) decreased from 20% in 1925 to 1930 to 7% in 1946. This reduction in medical student wastage was due mainly to the Moss Test’s ability to distinguish potentially successful from unsuccessful medical school candidates on academic grounds alone (McGaghie 2002, 1086–1087). After World War II, attrition rates rose again. In response, the Association of American Medical Colleges (AAMC) undertook a study to discover the possible reasons (Johnson and Hutchins 1966). At the time of this report, the average dropout rate was about 10 percent (Conger and Fitz 1963), with the majority occurring in the first year for both academic (about 60 percent of the total) and nonacademic reasons. Although it is not explicitly stated, the former were likely to have been students who were asked to leave and the latter departed voluntarily. The authors proposed that one way to prevent academic failures was to permit students to repeat years (i.e., the first attempts at “remediation”). Hence, by combining rigorous admission standards with

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intensive remediation for those students who “fell through the cracks,” schools would be able to guarantee that close to 100 percent of admitted students would go on to graduate. This report had a major impact: Within a few years, increases in undergraduate science GPAs and a more focused MCAT, along with more effective and intensive remediation for “strugglers,” lowered the attrition rate to less than 2 percent across the country, where it has remained ever since (Garrison, Mikesell, and Matthew 2007). In a follow up analysis nearly a decade later, Gough and Hall (1975) studied updated AAMC data as well as information from their own institution and confirmed these findings. But, perhaps ominously, they reported that “one reason for the reduction [in dropouts] is the increased leniency of medical schools in allowing students to repeat courses, and even years of work, and to take time out in order to resolve personal or some other problems” (Gough and Hall 1975, 942). It should be noted that this phenomenon of extraordinary graduation or completion rates is carried over to postgraduate medical education. Indeed, for the most common residency programs, the percentage of physicians who enter and successfully finish training is even more impressive than that in medical school. For instance, in the academic year 2008– 2009, the percentage of internal medicine residents who failed to complete training due to either dismissal or voluntary withdrawal was 0.8 percent of the total enrolled; for pediatrics, it was 0.7 percent (Accreditation Council for Graduate Medical Education [ACGME] 2009). Therefore, the overwhelming majority of students who enter medical school will graduate and finish their clinical training to the point of specialty board eligibility. On the surface, these data would speak to a remarkable achievement and would certainly mark the accomplishment of the goals set out both in the early 1920s and in the 1960s (Johnson and Hutchins 1966). Hence, for all practical purposes, admission to medical school turns out to be both a necessary and sufficient condition for graduation and eventual practice (ACGME 2009).1 But should it? 1

Of course, students must also pass all three parts of the United States Medical Licensing Examination (USMLE). The most recent data available from the National Board of Medical Examiners indicates that students are also successful in this arena (NBME 2009).

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A “Modest Proposal” If one were to assume that the ends of medicine are internal to the profession and that for these ends to be met a certain character is required of the physician, the crucial question becomes whether all of the students who graduate should be allowed to graduate. By “internal,” we mean that the goals and general professional conduct expected of doctors are set within an historical and contemporary context. The enforcement or regulation of these goals, via the setting of expectations of behavior and performance, come about through a collaborative effort of physicians and the representatives of the society they serve. We wish to consider two fundamental questions. First, are all neophyte students of medicine properly predisposed to become physicians—do all of them possess both the intellectual or academic ability as well as the constituents of personality, of strength and depth of character, that enable them to embrace their training and utilize its knowledge and skill to become doctors? Second, given the first components, are they all properly educated and trained to become physicians? The societal importance of high moral character and intellectual rigor in physicians has been a concern for many years. Relatively recently this has been relabeled as “professionalism” (Huddle 2005; Ingelfinger 1980; Starr 1982; Swick 2000; van Mook, de Grave, van Luijk, et al. 2009; van Mook, de Grave, Wass, et al. 2009; van Mook, van Luijk, et al. 2009). For instance, in 1878, Dr. Benjamin Hawker, a physician practicing in New York, was tried and convicted of performing an abortion, which was illegal at the time. He was sentenced to prison. Following his release, he attempted to resume his practice and, in 1896, was fined and prohibited from practicing due to an assumption of his poor moral character, which stemmed from his prior conviction of a crime.2 The law at the time stated that a conviction of any crime testified to a lack of fitness to practice medicine. Dr. Hawker appealed this decision to the U.S. Supreme Court, which upheld the statute in New York. The majority opinion stated that a doctor “should possess a knowledge of disease and their remedies, [and] should be one who may safely be trusted to apply those remedies. Character is as important a qualification as knowledge” (Hawker v. New York 1898, 194, emphasis added). 2

This would have been the case irrespective of the crime he committed: It was not specific to abortion.

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The medical school admissions process, no matter how painstaking, cannot be flawless, nor should we expect it to be. Medical educators should recognize, accept, and act on the greater duty owed to the public than any they feel may be owed to students. Seemingly well-qualified students may reveal deficiencies and shortcomings of intellect and/or character while experiencing the novel rigor and stresses of school, either in the classroom or the clinic. Problems with either one, or both, of these areas that are resistant to modest (and not repetitive) remediation should be grounds for dismissal. The fact that these students have been accepted on the assumption, using all of the tools we have available, that they are fully fit to perform the required work does not mean that the admissions process is structurally flawed. But, no process of this type is infallible, and this needs to be accepted and dealt with. Students can suffer from shortcomings in academic ability and/or character, either one of which should be sufficient grounds for dismissal prior to permitting the student to leave the confines of school or residency program to unfettered practice in society. While shortcomings in academic ability may be possible to remedy by repeating courses, tutoring, and the like, those of character are more dangerous and insidious and—we suspect—may be immune to remediation at this stage of a student’s psychological development. Therefore, medical schools should not shrink from their professional obligations to train doctors who will be a credit to their institutions, based on a misguided fear of litigation or some other form of retribution. Indeed, the medical professoriate may be unwittingly contributing to the problem (Cleland et al. 2008). Pellegrino and Thomasma have described the character traits required of the good doctor as “Aristotelian virtues” (Pellegrino and Thomasma 1981), fitting into their conception of medicine as a fundamentally moral enterprise (Pellegrino and Thomasma 1993). These virtues are often referred to as requiring cultivation for their full expression (Carr 2003). The frequent use of this descriptor implies the need for prolonged nourishment and growth and a time-dependent incremental acquisition of maturity for expression of the features of the character trait in question. Aristotle tells us that there are two kinds of virtue: that of thought, which arises mostly from teaching, and that of character, which results from habit (Aristotle 1999). But if it takes time to nourish the “virtuous” character, such that excellence becomes second nature, how can we

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introduce the virtues of the physician and then cultivate them in the short time of medical school? The answer, of course, is that we can’t. But we can nurture those already nascent or preexisting virtues, such that their continued care would be passed on to residency training directors and then older and more experienced colleagues, no different than in any other field.3 This perhaps also requires a more careful screening of the faculty to whom our students are exposed, especially in their early years before they have learned to discriminate between those who should and should not be role models, to distinguish those physicians whose cynicism has obscured whatever virtues they have or may have had (Burack et al. 1999; Coulehan 2005; Kenny 2007; Paice, Heard, and Moss 2002; Satterwhite, Satterwhite, and Enarson 2000; Weissmann et al. 2006). Learning to become a physician is a process during which the heart is educated together with the mind. Thus, physicians need to be trained in the sciences and in morals, in skills, and in the virtues. While physicians are “made, not born,” a vital component of medical education is the nurturing of qualities and personal features that are essential for the excellent (virtuous) doctor. It is important to note that, while character formation does not begin in medical school, it may be matured and directed there with some restrictions. Students matriculate into medical school with their character only partly formed, yet medical school plays an important role in the shaping and molding of this character. Indeed, Branch and his colleagues found that students begin by having strong empathic identifications with their patients, an empathy that eventually leads to respect and compassion (Branch 1998; Branch, Pels, and Hafler 1998). With time, students begin witnessing what has been labeled “moral erosion.” This shows that character can change during the years of medical training, although the change is happening in the wrong direction (Self and Baldwin 1998). Still, it is our contention that, if change happens in one direction, it can happen in the other. 3

We are not the ones to introduce the virtues; students come with a set of virtues to begin with. Our job as educators and mentors is to help them develop the virtues of medical professionalism, such as treating patients justly, utilizing and building upon their already extant virtue of justice. They are not virtue incarnated, but they cannot be vicious (or morally dead), and they cannot be a tabula rasa at this age, either. With time and experience, we hope they will develop phronesis (practical reason, or in Aristotelian formulation, the ability to know what to do, when to do, and for the right reason).

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Of course, educators, especially those who can serve as mentors or role models, can play critical functions in the maturation and instruction of students as they progress (Pellegrino and Thomasma 1993; Aagaard and Hauer 2003; Paice, Heard, and Moss 2002). It takes time and effort to both inculcate favored attitudes and behaviors and negate those that may be acquired by more informal means from peers or somewhat more senior colleagues. A study by Frellsen et al. (2008) showed an example of the ambivalent attitudes of medical educators toward upholding strict academic standards. In a survey of faculty who directed internal medicine core clerkships in U.S. and Canadian medical schools, the authors made some striking findings. First, they noted that the faculty members reported a wide variability of students who were having academic problems in the core clerkships, ranging from 0–15 percent. They also discovered that a very large percentage of these struggling students received a passing grade, seemingly at odds with their identification as underperforming. While attempts at remediation were widespread, the approaches taken varied greatly among the respondents’ institutions. Finally, there were also great differences in attitudes about sharing concerns about these students with fellow faculty members; those not in favor of doing so felt this might lead to a preformed bias against the students (a sort of self-fulfilling prophecy) that could be detrimental to students’ performance. For those students who have difficulty with academic content, the problems could be structural, meaning that for some reason these individuals do not possess the intellectual power that would enable them to achieve some minimal amount of required success. This is not amenable to remediation. It is not uncommon for such students to be intensively tutored and helped to pass their courses such that they progress to the next level. But this would not truly prepare them for an independent career in medicine, and students who are permitted to advance in this manner may have continued problems later on. Alternatively, academically struggling students could have what we might label “functional problems,” such as poor study habits, inadequate undergraduate education preparation, emotional difficulties, etc. All of these are potentially responsive to extra help, but there is no guarantee. For both groups we would hold that they should be subjected to a probationary trial period of limited duration, after which a final decision should be

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made for disposition of the student’s educational future. To drag out the situation interminably would be a disservice to both the student and the school. For some issues, such as emotional or psychological difficulties, a leave of absence might be appropriate, but one of finite length of time, after which readmission to school would be contingent upon resolution of the effects of the prior problems on academic performance. Many schools have instituted honor codes that may have a deterrent effect (McCabe, Trevino, and Butterfield 2002; McCabe and Trevino 1993), although maximum efficacy may require frequent reminders of the existence and purpose of the code (Mazar, Amir, and Ariely 2008). Nevertheless, there is little evidence to suggest that these efforts have diminished the incidence of errant professional or personal conduct in practicing physicians (Cohen 2006, 2008; McLachlan, Finn, and Macnaughton 2009; Papadakis et al. 2004, 2008; Kohatsu et al. 2004). Behavioral problems can be approached similarly— although it is likely (yet not assured) that there may be a prior history of malfeasance, the discovery of which may influence the degree to which remedial interventions may be employed for individual students. Hence, there may be functional problems, in which the student displays an affect or panoply of misconduct that is holistic, perhaps demonstrative of a personality that is not compatible with the intensely social, collegial, and altruistic nature of medical practice. While some educators may recommend that such students attend mandatory counseling programs, it is illusory to imagine that such interventions will be anything more than marginally successful. If this approach is taken—and it is certainly reasonable to do so, except for the most grievous of improprieties such as violent or criminal behavior —it should also be time-limited and retention in school or training program should be contingent upon a demonstration of acceptable behavior for the duration of the individual’s participation. On the other hand, students may have behavior problems that result from misinformation, immaturity, poor mentoring, or examples displayed by older students, house staff, or even faculty— the so-called “hidden curriculum” (Brainard and Brislen 2007; Burack et al. 1999; Hafferty and Franks 1994; Haidet and Stein 2006; Karnieli-Miller et al. 2010; Kenny, Mann, and MacLeod 2003; Satterwhite, Satterwhite, and Enarson 2000; Weissmann et al. 2006; Wright et al. 1998). This also includes substance abuse, which is one of the most commonly cited reasons

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for disciplinary action by medical boards (Boon and Turner 2004; Dubovsky et al. 2005; Leape and Fromson 2006; Papadakis et al. 2008). Often, these issues may be managed quite successfully with timely recognition and remediation. But once again, we would define success carefully and tie it contingently to no further display of the same or similar behaviors. Both good and bad habits and attitudes take root much earlier in life than the entry into medical school (Self et al. 1993; Self, Wolinsky, and Baldwin 1989; Patenaude, Niyonsenga, and Fafard 2003). A worrisome observation is the increasing trend of students to cheat both in college and in medical school and the apparent lax and somewhat forgiving attitude toward those who cheat (Anderson and Obenshain 1994; Baldwin, Daugherty, et al. 1996; Bilic-Zulle et al. 2008; Harding et al. 2004; Simpson et al. 1989; Rennie and Crosby 2001; Osborn 2000). Those who cheat in high school tend to continue this practice in college and graduate school (Happel and Jennings 2008; Whitley 1998). Hence, it may not be too much of a stretch to presume that individuals so disposed do not change their aberrant conduct in practice (Harding et al. 2004). Unfortunately, as suggested by a number of reports (Smith 2000; Glick 2001; Bilic-Zulle et al. 2008; Sierles, Kushner, and Krause 1988; Simpson et al. 1989; Stimmel and Yens 1982), educators’ response to cheating frequently takes the form of minimal remediation, thus permitting the student to advance and graduate. Undergraduate advisers may pay little attention to the potential for cheating on, for example, essays written for application to medical school. While this phenomenon has not been studied specifically, it does not appear to be the practice by either admissions committees or premedical advisers to routinely scan for evidence of plagiarism (K.L. Bergatto, director of AMCAS and AAMC, and Professor Daniel Scheirer, Duke University undergraduate premedical adviser, pers. comm. 2010). Cheating should not be considered as an isolated occurrence. It may be a symptom of a character flaw, a manifestation of a defect in the applicant’s disposition or judgment. This raises the question of what level or seriousness of offense, either academic or behavioral (“professionalism”), would be required to reach a threshold that would result in dismissal. In this light, it will be interesting to follow the institutional reactions to the recent report documenting high levels of plagiarism on application essays for entry to an internal medicine residency program (Papadakis and Wofsy 2010; Segal et

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al. 2010): Will hospitals start screening all applicants for evidence of academic malfeasance? Papadakis and her colleagues have been pioneers in correlating problems with “professionalism” in undergraduates and residents with later reporting to medical boards (Papadakis 2004; Papadakis, Loeser, and Healy 2001; Papadakis et al. 2004; Papadakis et al. 2005; Papadakis et al. 2008; Hodgson et al. 2007; Teherani et al. 2005). Their observations have recently been replicated in studies from England (Reid 2010; Yates and James 2006) and Canada (Tamblyn et al. 2007). While the significance of the conclusions drawn from their statistical analysis have been questioned (Colliver et al. 2007), the point they attempt to make remains valid. It is no doubt true that the majority of medical students or residents who have academic difficulties, including issues of questionable professionalism, will have careers with records bereft of public notice by medical licensing boards (although that may not be true of malpractice suits [Baldwin, Adamson, et al. 1996]). Nonetheless, these issues identify a group of students and young doctors who are at significantly higher risk of developing problems related to academic or humanistic competency. Most importantly, these data suggest that questionable behaviors and academic performance displayed early in a career (often as early as college) may not disappear with age, maturity, or even intervention. Pure academic, intellectual problems that students have in medical school may be easier to detect and potentially remediate, and, as noted previously, there may be a tendency by many medical schools to go to heroic lengths to enable students to pass their courses (Gough and Hall 1975). Recognizing, uncovering, and responding to difficulties with what has been called “professionalism” is more of a challenge, and it is unclear, first, if there have been any successful attempts to remediate what may actually be, in some cases, character flaws, and, second, if such attempts have been made using the correct approaches. Some have stated that there are degrees of plagiarism and culpability for its commission or that many students are not familiar with the definitions and content of academic misconduct when they graduate from college (Larkham and Manns 2002; Park 2003). We do not accept these explanations or excuses. There are accepted definitions of plagiarism, cheating, etc., that are standard components of both high school and undergraduate orientations and practice (Center for Academic Integrity 2010), so it is difficult to imagine that medical students can plausibly plead ignorance

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when caught plagiarizing or cheating. It is our belief that some behaviors are so antithetical to the virtues of medicine and so inimical and potentially destructive of the fiduciary relationship that is at the center of the social and moral contract medicine has with society that they cannot be explained away or forgiven. Honesty (and with it comes trust) is one of the cardinal virtues of medical practice (Pellegrino and Thomasma 1993), and any breach of it is an assault against the very foundation of the profession and cannot—and should not—be tolerated. It remains extremely difficult to gain admission to U.S. medical schools, with approximately 44 percent of applicants entering the 2010–11 class (AAMC 2012). While it seems reasonable to assume that the majority of students ardently wish to pursue careers in medicine for the right reasons, it is possible that some may lack the desired motivations for becoming physicians. For instance, it has long been known that doctoring “runs in families,” and it is at least conceivable that not all of these students want to enter the profession as much as their parents want them to (Huckle and McGuffin 1991). While there is no data to support this conjecture, it is plausible to postulate that these students may be predisposed to having academic challenges (hypothetically speaking). Finally, there are some students admitted to medical school who have marginal scores or undergraduate GPAs, but who fulfill some other qualification considered by admissions committees when filling a class, such as ethnic and regional diversity. It is possible (although not probable) that students who struggle academically and who may be those who would be more likely to be dismissed for academic or clinical acumen (although perhaps not professionalism) insufficiencies or failure might disproportionately come from these groups (Brewer and Grbic 2010). We fully realize that this may be an unfortunate byproduct of our call for enhanced academic educational rigor. However, this should not deter educators from fulfilling their ethical duty to society, as we call for in this essay. It does suggest that careful scrutiny and analysis of the demographics and undergraduate scholastic data for those students who are dismissed should be a component of all attempts to adhere to intellectual, clinical, and moral excellence. Nevertheless, the goal of making our medical school classes (and, thus, doctors) look more like the patients they will be taking care of is a laudable goal and should not be abandoned; it should still be possible to continue to achieve more

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demographic equality and heterogeneity without sacrificing adherence to these professional ideals.

Conclusion There can be little question that today’s doctors are both better educated and more qualified than their predecessors 50 or 75 years ago. Hence, it might be reasonable to assume that all of these young doctors were at least minimally qualified to practice medicine. But there are some students who have been permitted to graduate who should not be physicians. There is (and has been) a great deal of concern about the erosion of what is called “professionalism” in medical practice, which presumably starts during medical school, if not before. This term encompasses a group of character traits or behaviors that together make up those personal qualities that personify good doctoring. In reaction to this perception, medical educators have implemented formal undergraduate and postgraduate training to specifically address this component of medicine. It is unclear if these programs have been successful. The causes of this erosion may be varied, but could include both societal and individual failings that have led to a diminution of the importance of these vital character traits. While it is tempting to assign some, perhaps the majority, of responsibility to the change in generational attitudes, such as those ascribed to the “Millennial Generation” or “Generation Y,” this, too, could be a false attribution, since issues of diminished professionalism have preceded the generational transition. Given that at least some (but not all) of the disquiet about the quality of medical graduates has to do with lapses in professional behavior, it would seem to behoove medical schools and their faculty to require some quantitative measure of what they want students to be like. But that has proven to be a greater challenge than one might think (van Mook, de Grave, van Luijk, et al. 2009; van Mook, de Grave, Wass, et al. 2009; van Mook, van Luijk, et al. 2009; Bryden et al. 2010). Notwithstanding the difficulty in measuring this kind of performance, its singular significance to doctoring demands a continuation of research in this area to better understand how to teach professionalism, determine its absence or lower quality, and develop remedial interventions, if possible. If not, we should not hesitate to fail students who do not meet the highest standards we should expect of members of this line of work.

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We have suggested that the young people who enter medical school do so with their characters incompletely formed. It would thus seem essential that undergraduate and graduate medical educators be cognizant of this fact and that they undertake a major role in contributing to the development of their students’ disposition to acquit themselves with “right action” and instill in them the right virtues. While some may think that this is just professionalism in another guise, we think that professional behavior comprises an amalgam of personal traits and temperament with those attitudes that are nurtured by one’s mentors. Educators are both role models and guides and can contribute powerfully to the development of students’ ability to apprise clinical and academic situations with wisdom and increasing maturity (Kenny, Mann, and MacLeod 2003). A number of schools are experimenting with different and perhaps better ways of inculcating these important values in students and junior doctors; they bear watching and, if successful, merit wide incorporation into the medical curriculum (Carufel-Wert et al. 2007; Moberg 2000; Reed and Wright 2010). Who should be charged with upholding the standards of the profession with specific respect toward trainees? Ideally, it should be a collaborative effort between undergraduate and graduate medical educators, the various accrediting agencies and governing boards (such as the AAMC and the Liaison Committee on Medical Education), professional societies, and regulatory bodies such as state medical boards. Indeed, there is a reasonable consensus among these disparate groups on what constitutes professional behavior. However, the challenge remains the timidity with which those entrusted with maintaining the highest standards of the profession often approach the enforcement of these well-meaning standards. This is true of both professors and regulators, and the latter should not simply assume that medical graduates are absolutely guaranteed to be flawless. We recognize that those with the authority to monitor and maintain excellence in practice can be conflicted by what can be interpreted as competing duties with loyalty owed both to society and to the individual student or physician who may have transgressed the boundaries of acceptable conduct. However, we would maintain that it is not an evenly matched competition and that allegiance to the obligations owed to society and to patients far outweigh those owed to members of the profession. Alternatively, we could look to both the students we admit and our medical educators’ dedication to continued

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vigilance for signs of poor, and perhaps irremediable, behaviors that indicate individuals who will not, or cannot, become the kinds of doctors we wish to produce. Many years of data have demonstrated that we do an excellent job of accepting students into medical school who seem to possess the academic ability to perform well in the preclinical years. At the same time, we have some students who either have difficulty in passing their courses or exhibit worrisome behaviors. While our initial efforts are aimed at attempting to help these students overcome whatever obstacles they are experiencing, when our attempts at remediation are fruitless we may conclude the student should not be allowed to proceed (Petersdorf 1989; Reid 2010). To continue to do everything possible to ensure that almost all students graduate (and, later on, to do the same with residents), independent of whether they should graduate, fails in the fiduciary duty of medical educators to society and future patients.

Competing Interests The authors have no competing interests with reference to this manuscript.

Funding Support manuscript.

No external funding was used for this

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