This month AITSE decided to do something different from the usual series of short articles in order to give you a chance to take in a more significant piece of work by Dr. Crocker. Feel free to forward to your friends!
DISHONEST HEALERS: A Deadly Game
by Caroline Crocker, PhD
crocker@aitse.org
The first year medical student looked worried, "I don't know what to do. Most of my class is cheating and the teachers don't do anything about it. I've been offered a preview of the exams for $100 each. The only way to compete with the cheaters is to cheat. But, people's lives will depend on whether I really learn the material..."
"Massive amounts of cheating occur at this school. Entire exam halls full of people copying off people to the left, right, anywhere. All the professors know it. And nothing is ever done." A nursing student posted this complaint on line.
"What's your problem? This is how I got all my first author publications." This astonishing statement was by a professor at a University of California medical school after a student from whom he tried to steal first authorship of a research paper challenged him.
What do these vignettes have in common? They point to a basic problem: a crisis in medicine and the related disciplines that stems from a lack of integrity in academia. In fact, cheating in medical schools is becoming almost commonplace, with 58% of students admitting to having indulged in academic dishonesty.[1] A survey of nearly 2500 medical school students revealed that fully 39% claimed to have witnessed cheating.[2] Orange County physician, Dr. Rita Ellithorpe, asserted that, in her experience, medical school was all about cheating. And it seems that some cheating students do not even think it is wrong.
This has serious implications for our health as a nation. A group of three MDs and two PhDs wrote, "It is now evident that the American medical system is the leading cause of death and injury in the US." In a similar vein, the Journal of the American Medical Association published a paper stating that, "the iatrogenic [hospital or physician-caused] death rate dwarfs the annual automobile accident mortality rate." Even worse, the number they report is likely to be higher because less than 20% of these medical mistakes are ever reported as such.
What is worse is that a significant number of schools do not address academic dishonesty. According to a group of students from one medical school, cheaters who were caught in the act did not even receive a failing grade in the course. Apparently, these students were not disciplined, "because they are straight 'A' students...some of them are at the top of the class and receiving scholarships." Reports of a self-confessed drug-using student at the same university not being removed, despite having faked patient charts, are then not surprising. Evidently, what happened at University College in London, where a top-ranking and cheating medical student was allowed to qualify, also happens in America. Cheating may delay qualification, but it seems that it may not prevent it entirely.
Certainly, the intense time pressure, the drive to succeed and sometimes inadequate teaching, and even the practicalities of finances can lead to immense student temptation towards academic and even professional dishonesty. One medical student wrote on his student blackboard, "...we are punished for [asking questions] with condescending remarks...or [professors] rolling their eyes at us..." Another told me that, "The reason people cheat is that this is their whole future. Their morals may say don't cheat, but their house payment and student debt say they cannot afford to fail." Students who are at schools where cheating is not adequately addressed feel forced to cheat just to level the playing field.
That the dishonest behavior, once started, continues is borne out by the 2010 report of 139 physicians cheating on the internal medicine board exam. Apparently, those who took the exam would remember a question or two and provide Arora, a board review agency, with the information. Of course, these are the ones whose cheating was discovered. There are doubtless many who have not been caught. And this can have dire consequences, as witnessed by Dave, whose wife suffered unnecessarily at the hand of an incompetent and overconfident physician. He is now a grieving and angry widower.
While I was employed by Creighton University School of Medicine, Omaha, NE my supervisor asked me to help him with an urgent matter. This highly ethical professor and physician had assigned an Allergy Fellow (a qualified pediatrician) to write a chapter in a book aimed at allergists. But, the professor told me in some distress, he had just discovered that what the Fellow had submitted was 100% plagiarized. Furthermore, some of the sources were very out of date and, therefore, potentially harmful. He asked me to rewrite it, so I did. In this case, an upright Chief of Department caught the academic dishonesty before the plagiarism and inaccurate information were published, but this does not always happen. What if the person in the position of authority also engages in unethical behavior?
This is what occurred while I was working for a UK hospital, having been enlisted to help with a clinical trial comparing two antibiotic regimens. My assignment was to speak with physicians in the hospital, convince them to enter their patients into the trial, follow their clinical progress, and report the results. The pharmaceutical representative took those involved out for an expensive dinner and explained more of the procedure. She then made an astonishing offer: additional "perks" should we enroll a target number of patients. Since one of the medications was nephrotoxic (may cause kidney damage), I privately informed my supervisor, an eminent physician in the hospital, that I would not be advising anyone working on the kidney transplant ward to enter their patients into the study. But, to my horror, while I was on a two-week vacation, a kidney transplant patient was enrolled. Lack of integrity can be deadly for patients. The study was never published -- due to "inadequate controls."
Although, as Dr. Ellithorpe so eloquently said, "Our medical schools do not adequately prepare students for the momentous responsibility of being physicians and having the privilege of entering into the private lives of their patients," they should.
Dr. Bernard Brandstater is a delightful anesthesiologist who I asked about how cheating was prevented while he was in medical school in Adelaide. His answer was that in those days medicine was an honorable profession and honor meant something. The students did not cheat; the implied culture 60 years ago was that this simply would not be an acceptable practice. Dr. Brandstater has been teaching the history of medicine at Loma Linda University School of Medicine for over 40 years and does not seem to be aware of student cheating there either. A professor who was cheating was fired immediately. This university stresses, "educating ethicaland proficient Christian health professionals and scholars through instruction, example, and the pursuit of truth." They appear to be achieving their goal.
However, words alone do not make an institution great. Another school's website advertises that it is "...producing what this nation needs most: Health-care professionals who are technically excellent and compassionate caregivers." But, a professional who works for a hospital that hires graduates from one of the schools where students complain of cheating classmates told me, "...the physicians we get from them are the most poorly prepared for a residency program." It is possible that a reason for the alleged inadequate performance of many of the graduates in residencies is that, according to student reviews, cheating is rife because an over-the-top workload makes it difficult to succeed without cheating.
Professors at Samuel Merritt University (SMU) in Oakland, California have an interesting approach to dealing with the issue of student cheating. In response to my question, "What do you do to prevent cheating among your students?" Dean and Professor of Podiatric Medicine John Venson replied, "Nothing." The nearby teachers blanched visibly because they knew that the information being gathered was for publication purposes. He then clarified, "We don't try to prevent it because we want to catch the cheaters." Dr. Eric Stamps joined in, "We behave professionally and expect professional behavior from our students; we give cheaters the same consequences as they would receive from the medical board of California." After further questioning of faculty and students, a fascinating picture emerged.
The professors in this college work to make cheating unnecessary by limiting their intake and having professors who are gifted in teaching (according to their students) and available to students by cell phone seven days a week. Their examination system is equally student-friendly. The exams for first years are on Monday afternoons, so that the students have the weekend to study and Monday morning to sleep! All material is examined two weeks in a row and there are multiple opportunities to review and correct one's mistakes. As one student told me, "Their goal is to help us learn medicine and pass our board exams." Samuel Merritt University podiatry student Adam Tullis said, "It is not necessary to cheat because my profs do all in their power to help you master the material."
Of course, there are always students who would rather cheat than study. Most schools take the normal precautions to discourage cheating: students are instructed to leave backpacks at the front of the class, faculty are present in the room during exams, seating is assigned and the importance of academic honesty is stressed. But, medical students are highly intelligent and driven individuals and do not find it hard to get around these restrictions, especially when feeling the pressure that goes with medical training. For this reason, it is also important that the faculty and the students know each other-that is, they have a personal relationship. This in itself has been shown to reduce student cheating, perhaps partially because the modeling of professional ethics is dependent upon the students having a personal connection with the professors.
The problem with cheating in medical school and practice should be of great concern to all Americans: did your physician learn all the information they were presented with at medical school or did they cheat their way through? Would you knowingly put your or a family member's life in the hands of someone who does not consider this kind of behavior wrong, someone who might cut corners with patient care? Or would you prefer that integrity be maintained, that there would be honor in medicine?
Of course, not all medical students cheat and most physicians are compassionate and honorable healers. But it only takes one. Therefore, it is recommended that medical schools make sure that their professors model professionalism and act with integrity, students are helped to learn and apply the material, and all are aware that the needs of the patient must come first. After all, integrity in medicine doesn't just matter. It really matters.
ABOUT THE AUTHOR Caroline Crocker, PhD is the author of Free to Think: Why Scientific Integrity Matters and President of American Institute for Technology and Science Education.
[2]Baldwin, D.C. Jr, Daugherty, S.R., Rowley, B.D., et al. (1996) Cheating in medical school: a survey of second year students at 31 schools, Academic Medicine, 71, pp. 267-273.
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