Why Medical Schools Are Tolerant of Unethical Behavior

We are very grateful for the comment of Runyan on our article. We couldn't agree more with her perspective that there is a vicious cycle going on where unprofessional attitudes of faculty often lead to unprofessional behaviors in students and residents who someday may become faculty themselves further fueling the cycle. We believe that multiple approaches are required to stop that vicious cycle. Those approaches shall involve programs to reduce the occurrence of unprofessional behaviors and initiatives to increase the resilience of medical students and residents to avoid the "learning" and reproduction of those unwarranted lessons.

Competing interests: None declared

I applaud Vidal, et. al. for their courageous response to hearing a graduating medical student comment on the not-so-positive lessons learned in medical school, when, as they acknowledged, comments like these are swept under the rug on a regular basis.

Medical school, and residency training alike, is the breeding ground for the acculturation of medical professionals into an environment that is mentally, physically, and emotionally taxing. Unfortunately, good support systems to help physicians, and physicians in training, cope with these remarkable challenges and responsibilities are still not well established. The training years are the hardest, and the most isolating from family, friends, and a "normal" lifestyle.

While there are some initiatives to support a more well rounded approach to training, most of the time, the burnout that occurs due to lack of sleep, lack of time for reflection on one's practice, and the incongruence of day-to-day practice within the medical system and the provider's value system are breeding grounds for unethical and unprofessional behavior. In clinical years of medical school, continuing into residency, the physician in training is confronted with the 'hidden curriculum', which consists of the behaviors modeled by seasoned physicians, who often also suffer from burnout. These physicians may or may not be aware that they are modeling behaviors that stem from cynicism and disconnection.

This perspective, of course, does not fully address the fact that any and all unethical behavior should be addressed and the root case sought out. As the authors and previous commenters mention, this in and of itself is a large challenge, as it is difficult to objectively identify and remediate this behavior. However, I offer this perspective to point out a vicious cycle in medical training: cynicism and burnout in teachers/faculty leading to unethical/unprofessional behavior, which then leads to the same behavior in trainees who are first exposed to the modeling in medical school, and further to the inciting factors of burnout in residency.

If this cycle is to change, there must be courage, on the part of academic faculty who are responsible for students and residents, on the teaching institutions who run medical schools and residency programs, and on the hospitals who benefit from the work of residents and physicians. A healthy culture of medicine benefits not only providers, but, importantly, our patients. This can start with any individual, but for a culture change, the system needs to hear many voices. There are already leaders out there: Rachel Naomi Remen MD, Lissa Rankin MD, Pamela Wible MD, and many others. The American Medical Student Association offers conferences and leadership courses on these issues, as well as a month long rotation for 4th year medical students to explore holistic wellness and professionalism.

There is a sea change slowly (slowly) occurring. It is up to each and every one of us in the medical profession to recognize these moments of unethical/unprofessional behavior and to speak up each and every time. It is also up to us to support our colleagues, residents, and students in the effort to lead a balanced, holistic and well rounded career, for ourselves and for our patients.

Cited: The effect of the hidden curriculum on resident burnout and cynicism. J Grad Med Educ. 2011 December; 3(4): 503-510. (PMID:23205199 PMCID:PMC3244316)

Competing interests: None declared

We applaud the courage of both the graduation orator as well as Vidal et al for calling attention to a global problem in the health care profession. The authors cited several reasons why unprofessional behavior is tolerated, but perhaps the simplest answer was mentioned by Maxfield et al in the 2005 article "Silence Kills": confronting unprofessional behavior is difficult. It is therefore even more important that those in a position of authority embrace this challenge and begin the process needed to change our culture. The health outcomes of our patients depend on us to have at least as much courage as a new graduate.

Vidal EIO, Silva VS, Santos MF, Jacinto AF, Boas PJ, Fukushima FB. Why medical schools are tolerant of unethical behavior. Ann Fam Med. 2015 Mar;13(2):176-80. doi: 10.1370/afm.1763. Available in http://www.ncbi.nlm.nih.gov/pubmed/25755040 .

Maxfield D, Grenny J, McMillan R, Patterson K, and Switzler A. Silence Kills: The Seven Crucial Conversations in Healthcare. Available in http://www.silenttreatmentstudy.com/silencekills/SilenceKills.pdf

Competing interests: None declared

We are very grateful for the comments made by D'Eon, Hayton and Milne concerning our article. We agree with them that superficial policies and procedures will not be able to change the current culture of healthcare organizations that is paved with various degrees of disrespect towards patients, students and professionals. To change a culture is certainly one of the most difficult enterprises one could endeavor. First, we are so immersed in that culture that we often simply cannot see what is wrong because we learned to take it for granted and it became invisible to our eyes. Second, because it is dangerous to defy any established structure of power, as remarked by Schimmel and Hickson in their comments to our article.

Thomas Kuhn in his landmark work "The structure of scientific revolutions"(1) posited that old scientific paradigms do not change gradually into other newer paradigms but that the emergence of a new paradigm represents a complete rupture with the previous one. He called those periods of change "scientific revolutions" and stated that the process of change from one paradigm to another was only concluded when the followers/believers of the old paradigm died and were replaced by followers/believers of the new one. Unfortunately, as D'Eon, Hayton and Milne wisely remarked the longstanding dysfunctional culture of healthcare organizations does not seem to follow the same pattern described by Kuhn concerning scientific revolutions because students learn to naturalize and to reproduce the same dysfunctional patterns they have experienced during their training, and also because the rules of the hidden curriculum from every institution remain veiled and therefore cannot be addressed.

Almost 50 years ago Brazilian pedagogue Paulo Freire wrote his most important book entitled "Pedagogy of the oppressed" (2). In that book he posited that within a culture of oppression the ones who endure oppression eventually come to harbor their oppressors within themselves. By that he meant that the oppressed were made believe that their oppressors were so much superior to them that it was their right and duty to make choices for the oppressed; that if the oppressed would think and make decisions for themselves that they would inevitably err. Freire also believed that the harboring of the oppressor within the minds and hearts of the oppressed meant that the oppressed would learn to strive to become oppressors of others. Hence he argued that a true pedagogy of freedom should not target a simple change of roles between oppressors and oppressed but should aim to extinguish oppressive relationships. Quite interestingly that philosophy allowed Freire and his team to develop an alphabetization program that was able to alphabetize adults within 45 days. The remarkable success of his method was ascribed to the fact that it did not dissociate the learning to read words from the learning to read the World. We cannot help but wonder if his methods could be adapted to assist medical schools and other healthcare organizations to address their hidden curricula and change their culture for better.

References
1. Kuhn TS. The Structure of Scientific Revolutions. 3rd edition. Chicago, IL: University of Chicago Press; 1996.
2. Freire P. Pedagogy of the Oppressed, 30th Anniversary Edition. New York: Bloomsbury Academic; 2000.

Competing interests: None declared

We are very grateful for the comments made by Lima concerning our article. We agree with her that a system that is excessively focused on competition may foster attributes opposite to collaboration, compassion and solidarity. We believe that the culture of disrespect within the field of healthcare has more profound and older roots than the pressure to publish. We believe it is a reflection of the cultural background of our societies, where we praise the strong and the winners while disdain the weak and the losers. That culture of veiled and unveiled oppression teaches us in a silent but compelling way that some people have more value than others. This misperception is the basis for the depersonalization of the other, which is the starting point of dehumanizing relations as asserted by Brazilian pedagogue Paulo Freire almost 50 years ago.[1] We do not believe that we should wait the culture of our societies to undergo a profound change so that healthcare can follow. However we believe that if healthcare institutions could begin to acknowledge the conflict between our written values and the ones that we really practice; and if we could take a first step to change that picture, then perhaps the field of healthcare could help heal not only patients but also our societies.

References:
1. Freire P. Pedagogy of the Oppressed, 30th Anniversary Edition. New York: Bloomsbury Academic; 2000.

Competing interests: None declared

We are very grateful for the comments of Schimmel and Hickson and we are in complete agreement with all observations they made concerning our article. The experience of disrespectful behaviors exerts negative impact on the care of patients and the quality of life of healthcare professionals and students. We believe that disrespect for safety practices is another face of our professions and institutions' long-lasting culture of general disrespect. Furthermore we believe that that culture is rooted in the flawed unconscious belief that some people have more value than others. This degrading belief ultimately leads to the depersonalization of the other, which is fertile ground for any kind of disrespect. When we truly care for someone, we regard him or her as important as ourselves. But if we unconsciously believe that others (colleagues or patients) are less important than ourselves we become tolerant of a wide range of inappropriate behaviors towards them, such as not washing our hands before and after touching patients.

We also agree with Schimmel and Hickson that any endeavor to change the culture of an institution and to address unprofessional behaviors and milieus can be dangerous; that such a task should stem from genuine commitment of its leaders and that it requires several champions supported by a dedicated structure.

Finally we would like to thank those authors for providing us with inspiration through their pioneering work and research at the Vanderbilt Center for Patient and Professional Advocacy.

Competing interests: None declared

All three of us have personally experienced, witnessed, or been confidants related to unethical and unprofessional behaviour on the part of faculty or physician instructors. These behaviours range from bullying and personal attacks to sexism and sexual assault. And, like the authors, we have been bewildered at the tolerance of such conduct and are saddened at the prevalence of, and tacit support for, bad behaviour. It is indeed a serious systemic issue.

Not only do these cases of unreported and tolerated lapses of professionalism place patients at risk both directly and indirectly, but they do harm to the moral sensibilities of the medical students, residents, fellow physicians and other health care providers who are affected. We see the pernicious effect of this culture and how moral distress leads to decay and cynicism which then erode the fabric of medicine and slowly eat away at the heart of health care.

Students, even early on in their training, recognize "pure unethical behaviour" but are not empowered to challenge or confront these behaviours. They are restrained and crippled by the gaping power differential and they survive by rationalizing or ignoring these lapses in professionalism. This culture thrives when students become instructors or faculty members themselves and are often so mired and complicit in this ethically questionable culture that it may seem futile to attempt to challenge the behaviour of their colleagues or themselves. Sadly, many become so thoroughly socialized into this malignant culture that bad behaviour becomes normalized; they no longer identify some of these behaviours as unethical or undesirable.

Though we support the LCME's requirement that affiliated medical schools have mechanisms for reporting student mistreatment and though we believe that anonymous reporting has a role to play in improving the identification of repeat offenders, we realize that a few new superficial policies and procedures will not suffice. We need a concerted and sustained movement that addresses some of the fundamentally toxic aspects of the culture of medical education and medicine itself including, but not limited to, the hierarchy and power differential. Students (and faculty) must be taught to recognize that the reporting of unethical or unprofessional conduct is an important and institutionally supported component of their professional responsibility. They must see that whistle-blowers will be protected from the harsh treatment all too frequently experienced. Some of our fundamental expectations and habits of thinking and behaving need to change.

We would like to thank both the authors and the editors for bringing the paper to publication and for allowing us the opportunity to comment on this important topic. We also wish to add that unethical behaviour is tolerated in many other work environments and that medical education is not alone in need of a culture change.

Competing interests: None declared

The article by Vidal et al (2015) deals with the uncomfortable issue of unethical behaviors which occur in medical schools. Like a modern Pandora's box, discussing it could open our eyes to some of the evils of the (academic) world. In addition to approaching the identification and management it is important to understand the mechanisms underlying this behavior and its maintenance.

In this brief comment, I want to point out that perhaps the medical schools not only tolerate but indeed, encourage this behavior and create a "bad apples-friendly" condition. First of all, it is necessary to highlight that the competitive behavior can be against the networking and partnerships, both important issues in health care.

Seen this way, if the current culture at the university expressed in the mantra "publish or perish" isn't it feeding competitiveness and affecting the way we relate to each other in college? According to an important editor in the humanities and social science (Waters, 2006) the pressure to publish is destroying the quality of Educational Institutions. In Brazil, De Meis et al (2003) stated that scientific community is under pressure dealing with the conflict between increasing competition and diminishing resources. Although the study has been published more than 10 years ago, the current world economic situation does not seem to announce a more favorable context to solidarity and networking. It is possible that an even more uncomfortable idea than the existence of unethical behaviors at medical school is finding out that the current scientific production mode is supporting such behavior. Pandora's box is open and maybe, there are many other evils about to be released into the world

Vidal EIO, Silva VS, Santos MF, Jacinto AF, Boas PJ, Fukushima FB. Why medical schools are tolerant of unethical behavior. Ann Fam Med. 2015 Mar;13(2):176-80. doi: 10.1370/afm.1763. Available in http://www.ncbi.nlm.nih.gov/pubmed/25755040 .

Waters, L. 2004. Enemies of Promise: Publishing, Perishing and the Eclipse of Scholarship. Chicago: Prickly Paradigm Press.

De Meis L, Velloso A, Lannes D, Carmo MS, de Meis C. The growing competition in Brazilian science: rites of passage, stress and burnout. Braz J Med Biol Res [online]. 2003, vol.36, n.9 [cited 2015-03-19], pp. 1135-1141 . Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2003000900001&lng=en&nrm=iso&tlng=en . ISSN 1414-431X. http://dx.doi.org/10.1590/S0100-879X2003000900001 .

Competing interests: None declared