AMA Journal of Ethics^®

Case

Alex, a third-year medical student, is in the middle of his surgery rotation. He frequently finds himself rather shocked by some of the unseemly remarks that his attending, Dr. Tate, makes during surgery and between seeing patients on rounds. A highly respected surgeon, Dr. Tate is personable with patients and well liked by them, but his comments to his residents and medical students outside of patient earshot are often distasteful and inappropriate (e.g., “Sure I can fix his heart now but he’ll croak before Christmas” or “It’s hardly worth it to consent her—she’s way too dimwitted to understand a thing” or “This patient was here in January and is so fat that she literally broke the bed”). The other med students also seem put off by this behavior, but no one has said anything to Dr. Tate.

Almost every day at lunch, Alex relates several of Dr. Tate’s comments to his friends. Meg, another third-year on a different rotation, feels uncomfortable when Alex discloses these details. She pulls Alex aside after lunch one day and shares her concerns. “Alex, what happens on rounds or in the operating room is supposed to be kept confidential. I agree that Dr. Tate’s comments are distasteful, but I don’t think you should be gossiping to other students about him.”

Alex scoffs, “There’s nothing wrong with sharing an attending’s comments as long as the patient’s confidentiality is maintained.”

Commentary 1

In the mid-90s I met Ari Silver-Isenstadt, a medical student who had been asked by his school to take a year off from his medical training to pursue a master’s degree and, more importantly, to take a step back from what the school perceived to be his inappropriately confrontational behavior. While rotating through an affiliated hospital, you see, Ari had complained that the nametags provided to him by the hospital didn’t properly identify him as a medical student, as if the hospital were trying to hide his amateur status from their patients. The hospital didn’t take too kindly to his criticism. On a subsequent rotation through the ob/gyn clinic, Ari refused to “practice” a pelvic exam on an anesthetized woman because he wasn’t sure anyone had asked her permission. That put an abrupt end to his rotation.

Ari’s situation raises an important ethical question: When medical students witness, or are even asked to participate in, unseemly behavior, do they have a moral duty to do something? Or instead, as Alex’s case study forces us to ask: do they have a duty to remain silent, to protect patient and physician confidentiality?

Leaders at Ari’s medical school felt that he should have remained quiet in the face of such modest ethical breaches and waited to address these problems when he was in a leadership role himself. Indeed, when I was a medical student, I sat in on a case conference once in which an oncologist stood up and explained to the audience that, although the patient’s metastatic cancer was “incurable, the patient requested chemo anyway, so we offered him a cycle of salvage chemo. Unfortunately, the patient passed away the following week.” I was stunned by what I considered to be an example of cruel overtreatment. So I stood up, my short white coat announcing to the rest of the audience my lowly status as a medical student, and asked how this oncologist could justify “torturing this patient in the last week of his life.” After the conference ended, the chief medical resident pulled me aside and told me that, although he understood my point, I was only hurting my own career by confronting a senior physician in such a public manner.

No medical student should be expected to confront her superiors every time she encounters questionable behavior. Therefore, when Ari did choose to confront his faculty mentors, he was not responding to the call of moral duty. Instead, he was going beyond his duty—he was demonstrating moral courage. Where would our world be if no one took the risk of confronting powerful people when they believe those people are abusing their power?

What about Alex, then—the student in this case? Alex is not exhibiting morally courageous behavior by discussing Dr. Tate’s behavior with his classmates. Instead, I expect that Alex’s lunchtime conversations are an attempt to sort out his own moral and professional feelings. It is important for medical students to have these kinds of conversations. Medical students confront all kinds of morally questionable behavior during their training. They are exposed, as in Alex’s case, to shocking and inappropriate humor. If they simply ignore these ethical breaches, they may become immune to them, thereby following suit when they become attending physicians. It is really important for medical students to talk, at a minimum with each other, about the moral questions they face in their work lives, so they can better think through how to behave in their own futures.

Do Alex’s conversations violate some kind of intraprofessional confidentiality? No—Alex doesn’t owe Dr. Tate any kind of confidentiality. Tate, on the other hand, owes it to Alex to act as a better role model.

The real ethical question here then is not whether Alex should be able to discuss his moral concerns with his classmates. It’s whether Alex has a duty to go further, to act with moral courage and confront his superior. Confronting Tate head-on isn’t the right course, however, if Alex doesn’t think Dr. Tate would take such confrontation well. It probably won’t change Tate’s behavior, and will only end up hurting Alex.

It would be better instead for Alex to speak in confidence with the faculty member who organizes the surgery rotation for medical students. The confidentiality that matters in these discussions, by the way, is not any patient’s confidentiality. Alex doesn’t need to mention any patients by name in describing Tate’s behavior, and he certainly doesn’t have to protect Dr. Tate’s confidentiality—in fact he needs to let people in power know that Dr. Tate is behaving this way. The confidentiality that matters here then is Alex’s. He should be able to report Tate’s behavior to the powers that be without suffering undue consequences.

The preceptor should promptly determine whether Alex’s story holds up by interviewing students and others who work or have worked with Tate. If the story is substantiated, the preceptor should tell Tate that colleagues and supervisees “have witnessed inappropriate behavior” on his part and that if he doesn’t improve his behavior, he will no longer be allowed to supervise medical students.