During their educational life, medical students encounter several challenges, the origins and causes of which vary. This paper explores and attempts to scrutinize two of these challenges, before eventually introducing the concept of responsibility. First, this paper describes the general characteristics of medical schools, medical students, and medical education. Second, two different ethical challenges that medical students confront are then delineated: the anxiety of continuously questioning ‘while being trained, do I cause patients to receive suboptimal health care?’ and occasionally feeling obligated, consequently, to breach the ethical boundaries to practice procedures on patients. Finally, the faculty of responsibility and its components are introduced and discussed as a model that can overcome these ethical challenges.
Medical students, medical education, ethical challenges, patient involvement, peer-competition, faculty of responsibility
Medical schools are one of the most prestigious and sought after schools in the world, and getting into them is arduous. In order for a student to get into medicine, they must be hardworking and assiduous. Only those who competing for it at the highest levels can access it.
Medical students, being a chosen few among all students, endeavor to be good students, and they mostly maintain their prior attitudes and habits e.g. striving for higher grades. Given that medical knowledge is complex and not easy to acquire, this can lead to peer-competition between students. (1)
At the graduate level, medical education is traditionally divided between preclinical and clinical studies. In the preclinical part, students attend classes and learn requisite basic sciences such as biochemistry, pathology, histology, etc. In the clinical part, students attend rotations in different inpatient and outpatient clinics. They learn skills such as history taking, physical examinations, and surgical preparations as well as more specialized interventions, such as intubation, suturing, and prostate examinations. They have rotations in different departments to develop their practical abilities in that field.
When students advance through medical school, they face several challenges. (2) Although medical students typically become more resilient over time, intervening in the human body is an inherently demanding task. (3) The combination of the competitive structure of medical education, students’ aspiration to achieve the highest scores, and the rigor of the field make challenges inevitable. A remarkable number of studies have examined the various such challenges that students face. (2)
This article aims to analyze two interrelated challenges that most medical students confront: the anxiety of continually questioning ‘while being trained, do I cause patients to receive suboptimal health care?’ and occasionally feeling obligated, consequently, to breach the ethical boundaries to do as much practice as others. In particular, the article highlights the commonalities between the two dilemmas. Ultimately, the faculty of responsibility is presented as a key concept to cope with the ethical challenges medical students face.
Being trained, do I cause patients to receive suboptimal health care?
The first of the challenges that we are looking into relates to the involvement of patients in medical education. Throughout their education, and especially in the clinical part, students have to frequently deal with patients. The interventional clinical practices occasionally urge medical students to ask this question to themselves: Being trained, do I cause patients to receive suboptimal health care?
Medicine as a deep-rooted tradition is inherited from generation to generation. Patients take part in its transmission. In order for this noble art to be transferred and improved, humankind disregarded a fair amount of physical integrity, privacy, and confidentiality. Through such concessions, medical arts were able to make substantial progress. Mastering this art was not straightforward for physicians from the age of Asclepius to the present day. The fact remains that many people have paid the costs of this learning. Some people deemed themselves responsible and aspired for this duty. It is therefore important to keep in mind that medicine is an institutionalized sphere with professionals and trainees but also the essential component of patients.
In clinical practice, medical students are usually accompanied by a supervisor during bedside training or interventions. However, sometimes a suitable environment for education cannot be established due to technical shortcomings, forcing a student or a group of students to engage with the patient alone. (4) For instance, in the Emergency Department (ED) rotation, taking the blood gas (arterial blood) is the students’ duty, after they have learned how to do so. Since students are not well-experienced, on some occasions the procedure is not successful. Unsuccessful attempts of this sort discourage the students under training. The chaotic ambiance of the ED also hinders the optimum learning environment. (5) Actions such as inserting a needle into someone’s artery and causing it to bleed create a sense of giving harm despite the intent being the opposite. Moreover, equally stressful is that the learning environment for students –which is a workplace for healthcare providers and the route to seek remedy for patients- possesses more competent and adept masters.
Yet, students are not aware of the responsibility that they shoulder and the accumulation of such minor traumatic experiences precipitates the question: During the process of learning, do I cause patients to receive suboptimal health care?
Exacerbation of breaches: competitive structure
As seen in the aforementioned challenge, acquiring medical knowledge and practical abilities are burdensome. However, overly ambitious and tactless students triumph over such situations by pushing the ethical boundaries of training. These students permit themselves into all type of interventions on behalf of the medical experts, citing “the right to education,” and act as if they are the competent authority. Since control of that kind of behavior is not feasible in hospitals, many continue acting unethically, causing inequality of opportunity.
The second challenge that students face is thus the feeling of obligation to breach the ethical boundaries to do as much practice as others. To reiterate, the competitive atmosphere of medical faculties compels students to behave improperly. Few students remain strictly within ethical bounds; most others tend to breach boundaries either intentionally or unintentionally. A considerable number of medical students complain about the harm caused by their colleagues through the general atmosphere of the education. As one medical students narrates:
“When I come back to the resuscitation room, the patient had died and some of my friends were performing iv cannulation. I asked why they were torturing the dead body, and my best friend’s answer hit me like ton of bricks: ‘I will see you when you fail the practical exam’”.
Many students confess to such experiences when questioned. Given the time spent in the hospital and the many years of education, such episodes are increasing in frequency and this type of attitude is becoming common among students.
A number of articles have studied the depreciation of values and the decline of ethical sensitivity among medical students. For example, a study conducted in Philadelphia medical schools showed that as students advance in their training, they are less likely to tell patients they are students, despite it being an established ethical rule taught early on. (6) Peer-competition, among various other causes, encourages an increase of ethical violations gradually over the course of medical education.
Responsibility is an innate faculty that every human being possesses. It is a given tool that provides people to apprehend their duties and obligations. Different statuses assign us different duties. Every human being becomes aware of these duties, in a given situation, and faculty of responsibility is a natural skill that enables people to find out when they have an obligation to do something or have control over/care for someone, as part of one’s job/role. However, its improvement is crucial for using it full capacity. While its simplest function is to apprehend responsibilities to protect the self, the more sophisticated function of the faculty is for instance taking care of the environment for the posterity. At the ultimate level, it is to apprise one’s responsibilities towards God.
Most can utilize this ability at the lowest degree and it can be improved just like every other skill. It is important to note that its employment at the most basic level is essential to maintain daily activities. However, in different occupations, this may not be sufficient. Though its employment is very crucial during occupational life and may help to compass the assignments as well as to deal with everyday challenges, in the medical profession, having such a skill improved is vital since the main subject is human-life.
Improving the faculty of responsibility is essential not only for physicians’ practice but also for the time they are being educated as they need to utilize the faculty during educational years. (7) For the sake of example; apprehending the responsibility of protecting patient’s privacy and confidentiality is important for medical students, since they can achieve patient’s information. As the medical school is a period that their path cross with the patients for the first time, it is the most substantial period for doctors to improve their faculty of responsibility. (8)
On the other hand, medical education, the development of medical sciences, and its transmission necessarily invade the patient’s integrity. Some regulations apply to the form of these invasions to protect patient rights and to legitimize the breaches (e.g. informed consent) correspondingly. To implement such regulations and their entailments throughout medical education, student participation is critical. (9) In order for medical students to take part, improvement of the faculty is again necessary.
When a student switches role from a patient to a doctor, they need to develop sensitivities that go beyond technical knowledge. During this transition, the crucial achievement, in my view, is improvement of the faculty to be able to fully utilize it towards responsibilities. The responsibilities of a medical student are principally twofold.
The first is the responsibility towards patients who waived their integrity and made sacrifices for education. Students should admit that patients are the sine qua non of medical education and are generous to a fault by their waiver. With this attitude, students will be grateful to patients, which will lead them to proper conduct. This eventually decreases the harm and protects the best interest of patients. Once a student achieves the faculty of responsibility, s/he protects current and future patients.
The second is the responsibility towards the transmission of credible medical knowledge that has survived over centuries. As a link in the chain of transmission, medical students should acknowledge the responsibility and maintain the sense of mission to the noble art. The fidelity and dedication to the profession should be established during education years.
In daily practice, the prioritization of the two components is necessary. The first component should be prioritized in most cases not only because the primary aim of medicine is to promote and maintain the wellbeing of patients but also because the duty of transmission of medical knowledge is shared by all existing members of the profession.
Untying the knot
This paper has thus far explored two interrelated challenges from different perspectives and explained the faculty of responsibility. Here we should expand by looking at each case and the likely base from which challenges arise, and illuminate how the faculty of responsibility overcomes such challenges.
The first challenge which is to a large extent sentimental, seems to derive from the nature of medical intervention. When external factors related to the learning environment such as the chaotic atmosphere of ED, are added, oppression and inquiry are inevitable for students.
In the second case, the competitive atmosphere and corresponding depreciation of values may exacerbate ethical violations. However, the challenge is again related to the nature of the field and the missing sensitivity of some students to ethical boundaries. In other words, the blurriness of red lines and their insufficient perception by students cause unjustified breaches.
The common ground of the two at a glance is the nature of medical interventions. The ethical quandary concerning medical interventions is giving harm in appearance while trying to be beneficial. Justification of the harm is provided by the ultimate goal: to bring patients to a state of wellbeing. The dilemma of medical education is between the possibility to increase the harm given versus the benefit of future patients. (10) Preference between the two constitutes the basis of daunting challenges for students. The faculty of responsibility as a key concept is a functional instrument to cope with ethical challenges. It is detailed below, the implementation of faculty of responsibility for cases respectively.
The adoption of the faculty of responsibility by students, for the former challenge, will lead students first and foremost to protect the patient’s interests by not intervening without a supervisor when they are not well-trained. They will always bear in mind by virtue of the faculty that medicine is the art of science of restoring or preserving health. This awareness will prompt them to preserve the requisites of the science ab initio.
Second, difficulties that arise during training will not discourage students: with an eye to responsibility, students’ commitment to the field will be well-entrenched and they will not succumb to failures. Because they are au fait with the load they intent to shoulder, and are well aware of that even though the obstacles never end, endeavoring for the noble is virtuous.
For the latter challenge, those who adopt the faculty will not perform improper conduct since the right to education is balanced by the responsibility towards patients and the field at the intellectual and moral levels. Imbuing the faculty to medical students will decrease the number of tactless student. As a result, the inequality of opportunity and the atmosphere that exacerbate breaches will pose less of a challenge.
As to competition, although it is shown in some studies that the peer-competition is one of the leading causes of stress among medical students, it is considered as an effective teaching method in medical education. (1) If the competitive atmosphere is set properly through the faculty of responsibility, it will improve the permeation of virtues instead of exacerbation of breaches. Furthermore, it will motivate students to take responsibility and compete in good deeds.
The faculty of responsibility would relieve the discomfort and anxiety that students live with due to the interventions and the learning environment. Internalizing this faculty would help students to find their inner stability. While the faculty rationalizes the suboptimal healthcare that is presented to patients, it would obviate the misemployment of responsibility e.g. over-amplifying it to be better trained.
This paper first offered general characteristics of medical faculties, medical students, and medical education are compendiously given. The interrelated ethical challenges of unending questioning ‘being trained, do I cause patients to have less access to proper health care?’ and the feeling of obligation to breach the ethical boundaries to do as much practice as others were then discussed. The faculty of responsibility was offered as a way out of these ethical challenges because of its ability to remind students of their duties and to present an ontological ground.
Likely results of such challenges i.e. anxiety, depression, burnout and moral injury are not examined. Although there are many challenges that medical students face, only two interrelated challenges are included so as to not to digress from the main purpose. Methods of imbuing medical students with the faculty of responsibility are not proposed and are left for the experts.
This article was produced as part of the University of Chicago’s Initiative on Islam and Medicine Medical Student internship program under the mentorship of Dr. Aasim Padela, and underwritten by Dr. Sakina and Hossam Fadel.
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