1. Medical students’ understandings of
professionalism in response to ethical dilemmas
Presented at AMEE 2013
Dr Rosie Belcher, UCL Medical School
With thanks to
the students for their thoughtfulness and candour
my supervisor, Dr Catherine O’Keeffe

2. Background
• Medical students frequently encounter ethical
dilemmas during their training1-3
• These ethical dilemmas typically involve conflicts
between different elements or understandings of
professionalism4
• Learning to deal with ethical dilemmas
appropriately is an important part of becoming a
doctor

3. Methods
• 14 semi structured interviews
• Interpretative Phenomenological Analysis5,6
• Pierre Bourdieu7

4. Please tell me
about any
ethical
dilemmas you
have
experienced at
medical school
Mismatch
between medical
school teaching
and medical
culture
Difficulties due
to status as a
student, and
inability to
undertake
certain tasks
Witnessing
poor care, poor
communication
or unethical
behaviour by
others
Difficulties of
balancing
student’s need
to learn with
patient’s need
for care

5. Please tell me
about any
ethical
dilemmas you
have
experienced at
medical school
Mismatch
between medical
school teaching
and medical
culture
Difficulties due
to status as a
student, and
inability to
undertake
certain tasks
Witnessing
poor care, poor
communication
or unethical
behaviour by
others
Difficulties of
balancing
student’s need
to learn with
patient’s need
for care
I know things… aren’t in
keeping with how we’re taught
to do things… there’s a
difference between what
you’re taught and what
happens in reality

6. Please tell me
about any
ethical
dilemmas you
have
experienced at
medical school
Mismatch
between medical
school teaching
and medical
culture
Difficulties due
to status as a
student, and
inability to
undertake
certain tasks
Witnessing
poor care, poor
communication
or unethical
behaviour by
others
Difficulties of
balancing
student’s need
to learn with
patient’s need
for care
You see things that you know
aren’t right by established
doctors, or when you worry that
their practice is perhaps not as
good as it could be, and you
don’t feel you’re in a position to
do anything about that
Witnessing poor
communication with
patients, but not feeling
you're in a position to say or
do anything

7. Please tell me
about any
ethical
dilemmas you
have
experienced at
medical school
Mismatch
between medical
school teaching
and medical
culture
Difficulties due
to status as a
student, and
inability to
undertake
certain tasks
Witnessing
poor care, poor
communication
or unethical
behaviour by
others
Difficulties of
balancing
student’s need
to learn with
patient’s need
for care
Your need to become
competent and to perform,
versus the need to be
respectful to patients and also
maintain their safety, I think…
it’s a difficult trade off

8. Responses to ethical dilemmas
Immediate
• Comply or do nothing
• Remove themselves from
the situation
• Question or confront
– Both directly and subtly
Later
• Discussion with others
• Reflection, application to
their future self
• Take action to prevent a
similar situation for others

9. Just a Student
Student
Professionalism

10. Just a Student
Student
Professionalism
Students lack knowledge and experience
I do not know whether
[students] would…
know what is normal
and abnormal
We trusted the consultant,
he seemed really good.
Which is the majority of
the time, us trusting the
consultant, trusting our
seniors.

11. Students lack knowledge and experience
Students are disregarded and powerless
As a medical student…
I’m a nobody… nobody
knows who we are, we
don’t have names. We
are just a medical
student.”
Just a Student
Student
Professionalism
I feel like we are on the
edge looking in, most of
the time
I do know that… I’m at
the bottom of the
pecking order

12. Students lack knowledge and experience
Students are disregarded and powerless
Students should therefore be cautious
about passing judgment on others
Students are powerless to act
Just a Student
Student
Professionalism

13. Just a Student
Student
Professionalism
Students are becoming part of the
profession
As you go through the
clinical course you realize
that there isn’t going to be
this point where you are no
longer a medical student,
you are a doctor… the
change is a lot more gradual
than that
Patients do see you as
a member of the team,
they do look up to you
as sort of [a doctor];
sometimes you say,
“I’m a medical student.”
but they’re like, “Oh
thank you doctor” at
the end.

14. Just a Student
Student
Professionalism
Students are becoming part of the
profession
Students should have the same
standards of behaviour as doctors
We are integrating in to that
profession even though we
haven’t actually qualified
yet, we are doing all the
same things, and we have
to go by all the same ethical
guidelines

15. Just a Student
Student
Professionalism
Students are becoming part of the
profession
Students should have the same
standards of behaviour as doctors
Students should manage ethical
dilemmas, and unethical behaviour by
others in the same way as doctors

16. • Often in conflict:
– Student Professionalism would encourage students to take action
– Being Just a Student would discourage them from action
– Dilemmas often involved finding a resolution between the two
Just a
Student
Student
Professionali
smCombining the dispositions

17. • Often in conflict:
– Student Professionalism would encourage students to take action
– Being Just a Student would discourage them from action
– Dilemmas often involved finding a resolution between the two
• Sometimes in concert
– Students perceived deference to seniors as part of Student
Professionalism
Just a
Student
Student
Professionali
smCombining the dispositions
I didn’t, and I shouldn’t have [taken
a particular action]. I was right not
to, because it wouldn’t have been
my place to undermine any member
of the clinical team

18. Our response
• Setting the ground rules
– It’s OK to question
• Improving belonging
• Challenging others and being open to challenge
I think it’s important to be able to
say these things in a nice, non-
criminalising way… it takes
practice.

19. Take home message
• Ethical dilemmas for students are common
• They stimulate reflection and discussion on
professionalism
• Students understandings of professionalism can inhibit
them from taking action
• Educators can incorporate students personal ethical
dilemmas into the curriculum
– to assist students in forming their own understandings of
professionalism
– To assist students in responding appropriately

20. References
1. Christakis, D.A. & Feudtner, C., 1993, Ethics in a short white coat: the ethical dilemmas
that medical students confront, Academic medicine, 68(4), pp. 249-54.
2. Feudtner, C., Christakis, D.A. & Christakis, N.A., 1994, Do clinical clerks suffer ethical
erosion? Students' perceptions of their ethical environment and personal development,
Academic medicine, 69(8), pp. 670-9.
3. Monrouxe, L.V. & Rees, C.E., 2012, "It's just a clash of cultures": emotional talk within
medical students' narratives of professionalism dilemmas, Advances in health sciences
education: theory and practice, 17, pp. 671-701.
4. Ginsburg, S et al, 2000, Context, conflict, and resolution: a new conceptual framework for
evaluating professionalism, Academic medicine, 75(10 Suppl), pp. S6- S11.
5. Smith, J., 2003, Qualitative Psychology: A practical guide to research methods, Sage
Publications, London.
6. Smith, J.A., 1996, Beyond the divide between cognition and discourse: using
interpretative phenomenological analysis in health psychology, Psychology and Health,
11(2), pp. 261-71.
7. Bourdieu, P., 1977, Outline of a Theory of Practice, Cambridge University Press.