Monday, January 21, 2008

Teaching Cynicism and Arrogance along with Medicine

Inside Medicine: An Unfortunate Part of Learning Medicine By Dr. Michael Wilkes -

Every medical school has a formal school curriculum that is geared toward ensuring that students can pass their national exams and become licensed doctors. Training geared toward passing exams is a relatively easy task given that we accept highly intelligent students with proven track records in academics.

However, every medical school also has a hidden, or untaught, curriculum that is not written at a Web site or in any catalog, and about which the faculty is largely unaware. Many researchers who have studied medical education observe that students come to medical school with a strong sense of social-mindedness, altruism and community service.

However, the researchers observe that for some students, interest in the patient, altruism, and social awareness decline as the student advances in the studies. Some refer to this as cynicism, selfishness or arrogance.

As an American Association of Medical Colleges publication points out, the final year of medical school is when students reach a pinnacle of cynicism – becoming even more cynical than residents or faculty members.

This is not the fault of our formal courses or the printed curriculum. Our lectures and discussions strongly emphasize ethics, professionalism and issues related to respecting and understanding the patient as an independent decision-maker. But the influence of coursework pales compared with the power of the untaught curriculum – the influence of exposing students to what we actually do with patients and colleagues rather than what we say we should do.

For medical students, the most powerful influence on their learning, and in shaping behaviors and attitudes, comes from observing residents and faculty members in their practices.

We can teach extensively about the appropriateness of respecting different cultures, different beliefs and different health practices, but when thestudent hears a resident dissing a patient's mistaken notions of disease, or hears them making fun of a patient's body, the lesson is clear – to be a part of the "club," this is the expected behavior.

Students are extremely observant. They see us ignoring patients who don't speak our language, not entering the room of the patient who has a terminal prognosis, not offering to help the overworked nurse who is trying to answer three patient call buttons at the same time, poking fun at other medical specialties, and minimizing the time spent with a person who belongs to a social group we don't like.

Residing, as medical students do, at the bottom of a strictly defined hierarchy, their goal is to excel and fit in to their surroundings. They watch the doctor's every move – where we stand when we are in the operating room or at a patient's bedside, what we wear, how we talk about our family life, what we drive, and how we treat staff members with whom we work.

After all, students are graded subjectively on their clinical performance, which includes how they behave and interact with the doctors. A heavy part of medical school is being socialized to be a doctor.

Given that there is a strong social drive – and academic need – to belong to the group, be it with surgeons, psychiatrists, pediatricians or the like, it is not surprising that students model the behaviors they see.

For some, these behaviors learned from observation slowly get incorporated into how they will act when they complete their training. Other students can turn their behaviors off as soon as they leave that course or clinic. Still others don't alter their beliefs – they perceive the medical teaching environment as cynical for teaching students one thing in the classroom and quite another in the clinics and hospital.

Unfortunately, these last students often are subject to grade retaliation for not "working to fit in with the team" or for "disagreeing and confronting a resident or other senior member of the team."

Perhaps the lesson for us all – doctors, students and the public – is that our behavior is watched, and that those around us can learn important unintended lessons by what we do, rather than what we say.

About the writer:
  • Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at

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