Health care professionals sometimes encounter situations in which they need to speak up to prevent harm, ensure better care, and/or address unprofessional behavior. This important part of living an ethical life is especially difficult for medical students because they have less experience and knowledge, are concerned about their grades and evaluations, and want to maintain good relationships with their residents and attendings.1–3
Consider one example encountered and described by a student who participated in the ethical action exercise that we describe in this Innovation Report. On the first day of his neurology clerkship, this third-year medical student was assigned to the stroke consult service. That morning a resident was paged to evaluate a patient with symptoms of a middle cerebral artery stroke. Because the stroke had occurred fewer than three hours prior, the resident discussed administering a tissue plasminogen activator (tPA) with another resident. The residents saw no contraindication to tPA, so one called in the order to the pharmacy. While the residents were discussing the matter, the student looked at the electronic medical record and noticed that the patient had received heparin the day before.
The student explained why speaking up was difficult:
I wanted to make a good impression, and contradicting my resident was probably not the best way to do that. Also, I hadn’t seen the coagulation studies to know if tPA was contraindicated, so I wasn’t sure I was right. If I was wrong, I might look stupid and get a bad grade. If I was right, I might come off as a know-it-all student.
But the student realized why he needed to act:
Simply put, a patient’s life was in danger. Getting tPA is dangerous, and in the presence of contraindications, it is much more dangerous. The patient could bleed to death. The worst that could happen to me was that I would get a bad grade.
So the student spoke up. The residents checked the medical record, saw that the patient had received heparin, and looked up the coagulation studies. The patient’s partial thromboplastin time was extremely prolonged. One of the residents called the pharmacy and canceled the order. Both residents thanked the student.
Consider another example, again from the ethical action exercise described in this report. An 18-year-old patient came into a family medicine outpatient office for his first checkup after female-to-male gender reassignment surgery. As soon as the nurses saw his name on the schedule, they seemed excited about the chance to see a “freak.” “So, is it a he, a she, or an it?” asked one of the nurses as she made a disgusted face. Another nurse commented, “I want to see it,” referring to the surgically constructed penis.
The third-year medical student went with her preceptor to examine the patient. During the examination, she noticed multiple scars on the patient’s left wrist. She had seen one other transgender patient, and he also had scars on his wrist. The student reflected, “These markings confirmed my cursory knowledge of the struggles that transgender people have, and I was angered by the nurses’ attitudes.”
The student thought about her work and responsibility:
One of the most important factors that led me to medicine was the desire to empower those who are marginalized and to close the gap between them and the rest of us. The language that I heard and the attitudes that I sensed divide “us” from “them” and increase the gap that I am working to close.
After the patient left, the nurses bombarded the preceptor with questions. The student spoke up: “Gosh, he had big scars on his wrist. I feel really sad that he had to go through that.” Then one of the nurses who had remained quiet spoke up. She explained that her brother Danny used to be Danielle. The whole conversation shifted from insensitive banter to concerned inquiry.
Of course, outcomes are not always positive, as in these two examples. Situations are not always so clear-cut, students are not always right, people involved are not always receptive, and speaking up does not always improve care or change attitudes. Still, to advocate for a patient’s welfare, students must learn to speak up—in the right way, at the right time, and for the right reasons.
Medical ethics education has not ignored the ethical issues that students encounter, including the problem of speaking up.1–3 Much of this education, however, tends to ignore the ethical tradition, running from Aristotle4 through William James,5 that emphasizes action as the starting point of living an ethical life. Action helps to form dispositions or habits, and habits combine to form character.6 Because of the crucial role that habits play in living an ethical life, Aristotle taught that it is important to acquire good habits “right from our youth.”4
Paraphrasing Aristotle, we say that it is important to acquire good habits of speaking up right from medical school. The idea here is not so much to inform students about the ethics of speaking up as to help them form an active disposition to speak up when appropriate. But how to do that? Mindful of the connection between actions and habits,7 , 8 we designed our ethical action exercise for medical students. Here we describe the ethical action exercise, our evaluation of the first students who completed it, and our plans to complement the ethical action exercise with other initiatives.
We incorporated the ethical action exercise into Clinical Bioethics, a required course at State University of New York Upstate Medical University. The small-group course meets monthly concurrent with third-year clerkships. The course has always included a reading about speaking up,1 and students often raise examples from their own experience,3 but beginning in the 2013–2014 academic year, the course included the ethical action exercise which requires students to:
- Actively look for problematic situations during the next four to five months, and
- Actually speak up to try to correct, resolve, or improve one situation.
The first part of the assignment is important because actively looking is a key part of living an ethical life. The second part involves overt action, but the students determined for themselves where, when, and how to act. The assignment emphasizes action:
You can fulfill this assignment only by actually speaking up in a real situation. The assignment is not to think about what you would or should do later, when you are a resident or practicing physician. The assignment is to speak up at least once during the next few months.
The assignment requires students to write a report answering six open-ended questions. (Full instructions for the assignment are available upon request.) The students receive a pass or fail on the assignment based on whether they satisfactorily completed the report; students are not graded on the adequacy or outcome of their action.
We realize that this exercise might result in negative consequences for some students. They might experience discomfort, difficult conversations, biased evaluations, or even recriminations. Despite these possibilities, we believe that, in many cases, students have an ethical responsibility to speak up, particularly given their responsibility to promote patient welfare.1 Furthermore, we allow the students to choose when and how to speak up.
After the inaugural class of students completed the ethical action exercise, our staff assistant deidentified the written reports, and the university’s institutional review board deemed the evaluation of these reports to be exempt from institutional review board (IRB) review. We then examined the reports submitted from all 115 students at the Syracuse campus during the 2013–2014 academic year.
We developed preliminary categories for the students’ responses and independently coded 20 reports. We discussed disagreements in coding until we reached agreement. After revising the categories, we then coded all 115 reports using these categories. Initial independent interrater agreement was 77% and increased to 100% after discussion.
We examined 115 reports and excluded 4 from further analysis because their student–authors described problematic situations but did not actually speak up. The remaining 111 students spoke up about issues occurring in all of the required clerkships in rough proportion to the duration of the clerkships; that is, overall students wrote more often about situations in the longer clerkships (data available on request). Table 1 shows our analysis of the 111 reports.
Most students (n = 78; 70%) spoke up about situations in which they thought some aspect of patient care—physician–patient interaction, diagnosis, treatment, documentation, discharge, or follow-up—could be improved. Others (n = 32; 29%) spoke up when they perceived unprofessional conduct (e.g., jokes about patients, insensitive language, or judgmental attitudes toward patients who are obese, transgender, or incarcerated).
In most situations (n = 96; 86%), students found speaking up to be difficult. Some of the difficulty related to concerns about evaluations and inexperience. Over half the students found speaking up difficult because of their relationships: They had good relationships with residents and attendings and wanted to show respect, gratitude, and humility; or they had a difficult relationship and did not want to irritate the person; or they had a new relationship and were unsure how to act.
Students’ speaking up led to a reasonable discussion or improved care in the majority (n = 67; 60%;) of cases, as determined by our judgment of the students’ reports. Further, as a result of completing the ethical action exercise, only 2 of 111 students reported becoming less likely to speak up in the future, whereas 64 students reported becoming more likely to do so (the remaining 45 students did not indicate that they were more or less likely to speak up). Becoming more likely to speak up is an understandable result when speaking up led to a reasonable discussion or improved care, but of the 64 students who reported being more likely to speak up, 21 reported that the results of their speaking up were either insignificant or unknown.
In 12 cases, students experienced some negative reaction: stern words, expressed irritation, belittlement, or, in one case, a critical remark in the student’s evaluation. Table 2 shows results from these 12 students. Even though these 12 students received negative reactions, 7 reported being more likely to speak up in the future, and none reported being less likely.
The ethical action exercise has proved to have many merits. In most cases, speaking up led to better care of patients or to reasonable discussions about care. Additionally, most students reported being more likely to speak up in the future. Students also recounted gaining a variety of insights—about their own conduct and values, and about clinicians and their practices. The ethical action exercise has even had an unexpected social effect: Students sometimes conferred with each other about situations, expressed commitments to one another, and supported classmates who spoke up.
Of course, our innovative exercise also raises many issues. Going forward, we want to address three key issues. The first concerns habits. Although many students reported that they were more likely to speak up in the future, we do not know whether students developed lasting habits of speaking up. We want both (1) to add practices that reinforce the habit of speaking up and (2) to study fourth-year students’ experiences and practices.
The second issue concerns culture. Some may object that the ethical action exercise has the wrong focus, arguing that instead of trying to develop the students’ habits, medical educators and leaders should try to change the culture of medicine. Although some aspects of the culture of medicine discourage speaking up (e.g., rigid hierarchies), other aspects encourage doing so (e.g., emphasis on patient welfare). Furthermore, the two choices represent a false dichotomy. The medical community does not need to select either developing habits or changing culture. Both are important. Going forward, we plan to talk about speaking up and institutional culture at grand rounds in every clinical department to make faculty and residents more aware of how they might encourage others to speak up.
The third issue concerns other initiatives. Many initiatives in medicine aim to improve communication, build more effective teams, ensure patient safety, and improve the quality of care. Connecting these initiatives and ours is vital. All of this work emphasizes the ideal of patient welfare and an ideal of social democracy—that all the people who are involved in a given practice should contribute to the practice as much as is reasonably possible.9
Much in medicine must change to continue to improve patient welfare. Although no single, simple solution will bring about the needed change, we believe that the ethical action exercise moves us in the right direction.
The authors wish to thank Gregory Eastwood, MD, and Thomas Curran, MD, for integrating the ethical action exercise into the Clinical Bioethics course. They also wish to thank the students who have completed the exercise for their engagement, including the two anonymous students whose reports serve as examples in this Innovation Report. The authors also wish to thank Jessica DeJohn Barbuto and Lauren Zahn for providing administrative support.