Does Medical School Educate Does Medical School Educate for Professional Values?for Professional Values?

Brezis M, Butt O, Haimov T, Shapiro S, Ilan U, Brezis M, Butt O, Haimov T, Shapiro S, Ilan U, Cohen R, Tal M, Rubinow A Cohen R, Tal M, Rubinow A

Hadassah-Hebrew University Medical CenterHadassah-Hebrew University Medical CenterJerusalem, IsraelJerusalem, Israel

Professional schools, such as Professional schools, such as medical, nursing, business and law medical, nursing, business and law schools, do not educate for valuesschools, do not educate for values

Professor Lee Schulman Professor Lee Schulman President, Carneggie Foundation for EducationPresident, Carneggie Foundation for Education

http://upload.wikimedia.org/wikipedia/en/9/9a/Enron_Logo.svg

Ex-Finance Minister Hirschson Sentenced to 65 Months In Jail

In the Holy Land…

The corruption industry

MP Benizri (Shas) gets 18 months’ jail for corruption

Former Minister & Party Leader

Deri Begins Serving 3 year Term

Prison for Corruption

Deputy Head of Oncology convicted

of taking bribes from patients

Tax Authority Director resigns amid corruption

allegations

Top gynecologist charged with

fabricating medical data (head of

hospital's Helsinki Committee)

www.transparency.orgwww.transparency.org

Misconduct is a Misconduct is a global challengeglobal challenge

One-third of researchers surveyed in One-third of researchers surveyed in China admit to plagiarism, falsification China admit to plagiarism, falsification or fabrication of data. or fabrication of data. Nature (2010)Nature (2010) UK journal Acta Crystallographica retracted 70 published crystal UK journal Acta Crystallographica retracted 70 published crystal structures - fabrications by researchers at Jinggangshan structures - fabrications by researchers at Jinggangshan University in Jiangxi province. University in Jiangxi province.

Tainted Heparin from China Tainted Heparin from China Cause 81 Deaths in U.S.Cause 81 Deaths in U.S.

Lead in Toys

Lead in Toys

Tainted milk scandal resurfaces in China

Industry’s Misconduct Involves ProfessionalsIndustry’s Misconduct Involves Professionals

Cheating at Israeli UniversitiesCheating at Israeli Universities

Self Reported Cheating at Nine Law Faculties

N=788 studentsCheshin Y, 2002, 2005

Rate of Students Admitting ViolationsRate of Students Admitting Violations(≥2, at exams, assignments or clinical activities)(≥2, at exams, assignments or clinical activities)

80% 97% 31%80% 97% 31%

O. ButtO. ButtThe Medical The Medical

TeacherTeacher20092009

Cheating at Medical SchoolCheating at Medical School

Response Response raterate

Teachers viewed students’

dishonesty problems as not

part of their job to deal with them

E.g., performing intimate examinations without receiving

patient’s consent

No easy solutions to cheatingNo easy solutions to cheating

Technical (Technical (e.g. e.g. camera surveillance): limited camera surveillance): limited and easily defeated by student’s creativityand easily defeated by student’s creativity

Disciplinal: heavy to implement because of Disciplinal: heavy to implement because of legal implications legal implications

Physicians in Health Care CorruptionPhysicians in Health Care Corruption

• Fabricated ResearchFabricated Research• Pharmaceuticals or DevicesPharmaceuticals or Devices• Dubious Research on PollutionDubious Research on Pollution• Misconduct in ManagementMisconduct in Management

T. Haimov, The Medical Teacher, 2009T. Haimov, The Medical Teacher, 2009

Survey of Final Year Medical Students in a Leading Faculty Survey of Final Year Medical Students in a Leading Faculty (representing 1/3 of students concluding studies in Israel) (representing 1/3 of students concluding studies in Israel)

Percentage of Students %

Lifestyle EducationLifestyle Education

““Practicing a healthful behavior was Practicing a healthful behavior was shown to be the most consistent and shown to be the most consistent and

powerful predictor of physicians powerful predictor of physicians counseling patients about related counseling patients about related

prevention issues” prevention issues”

Nutrition 2009, 25: 532Nutrition 2009, 25: 532

& review from the Centers for Disease& review from the Centers for Disease

Control and Prevention 2009Control and Prevention 2009

www.atzuma.co.il/shvilhadassah

::רפואהרפואה תלמידיתלמידי בקרבבקרב לבריאותלבריאות חינוךחינוך והרצויוהרצוי המצוי המצוי??בריאבריא חייםחיים אורחאורח מעודדמעודד כרםכרם בעיןבעין הקמפוסהקמפוס האםהאם

' ' גג שנהשנה לרפואהלרפואה סטודנטיםסטודנטים יי""עע שהוכןשהוכן חח""דודו 20102010 קיץקיץ

ʯ́ ʲ ʬʬʷʸ ʺ ʥʩʤʨʬʥɹ̫ ʤʬʹ ʺ ʩ́ʠʸ ʤy ʶʧʡʬʥʫʠʬʥ

ʢʷʰʣʥɹ

ʭʩʩhɹ ʥʠʺ ʥhʧʤʬʸ ʹ ʠʮ

ʠʩyʡʭʩʩʧʧʸ ʥʠʣʣʥ̡ʬʤʨʩɦʸ ʡʩhʥʠʤʬʹ ʪy ʣʤʥʦʭʠʤ

"

ʭʸ ʫʯʩ̡ʬʭʥʩʬʫʭʩʡʫʥy̋ ʥ́y ʲ

Example of a Healthy Campus at Stanford University

Healthy Living Center at Mayo Clinic (Rochester, MN)

FORTUNE Magazine: Mayo Clinic One of Best Companies to Work For

1$1$השקעה של השקעה של לקידום בריאות לקידום בריאות

6$6$בעבודה מניב בעבודה מניב בפריון העבודהבפריון העבודה

Percentage %

Attitude Towards Organ DonationAttitude Towards Organ DonationSurvey of Medical Students (N=192) and Teachers (N=68)Survey of Medical Students (N=192) and Teachers (N=68)

In recent years, our school has In recent years, our school has changed the admission process changed the admission process with inclusion of psychological with inclusion of psychological testing to select students with a testing to select students with a more desirable personality. Our more desirable personality. Our

school has also introduced a school has also introduced a program of humanistic courses. program of humanistic courses.

In recent years, our school has In recent years, our school has changed the admission process changed the admission process with inclusion of psychological with inclusion of psychological testing to select students with a testing to select students with a more desirable personality. Our more desirable personality. Our

school has also introduced a school has also introduced a program of humanistic courses. program of humanistic courses.

Has cheating decreasedHas cheating decreased??

%

In your opinion, was there a cheating In your opinion, was there a cheating problem at the last exam?problem at the last exam?

NoNo

I cheated myselfI cheated myself

I helped others cheatingI helped others cheating

1-5 students cheated1-5 students cheated

5-10 students cheated5-10 students cheated

10-30 students cheated10-30 students cheated

Over 30 students cheatedOver 30 students cheated

N=96N=96

%

Do you see a problem in cheating?Do you see a problem in cheating?

I don’t have a problem I don’t have a problem with this behavior with this behavior

I have a problem with I have a problem with this behavior and I this behavior and I

oppose itoppose it

Students see a system of competitive Students see a system of competitive evaluation & incentives (e.g. scholarships), evaluation & incentives (e.g. scholarships), exclusivelyexclusively based on factual knowledge and based on factual knowledge and

not on attitudes, behavior, skills & valuesnot on attitudes, behavior, skills & values

“You, teachers, look only at our grades”

Knowledge is less important than the ability to admit you don’t know and the skills to find out answers to what you don’t know

At medical schoolAt medical schoolstudents unlearn to say “I don’t know”students unlearn to say “I don’t know”

A cab hits in hit-and-run accident. 15% of A cab hits in hit-and-run accident. 15% of cabs are blue, 85% are green. An cabs are blue, 85% are green. An eyewitness states cab in accident was blue; eyewitness states cab in accident was blue; its testimony has sensitivity & specificity of its testimony has sensitivity & specificity of 80%. What is the chance that a blue cab 80%. What is the chance that a blue cab caused the accident?caused the accident?

Overconfidence Among Medical Students in Overconfidence Among Medical Students in Cognitive Biases (à la Kahneman & Tversky) Cognitive Biases (à la Kahneman & Tversky)

Don’t Don’t knowknow

1%1%

%%

You donated blood, out of good health. You donated blood, out of good health. HIV test is positive. The sensitivity and HIV test is positive. The sensitivity and specificity of the test are 99% each. specificity of the test are 99% each. What are is chance you are HIV carrier?What are is chance you are HIV carrier?

%%

Don’t Don’t knowknow

1%1%

Should Oocyte Cryopreservation Be Allowed for Personal Reasons?Should Oocyte Cryopreservation Be Allowed for Personal Reasons?

Medical Medical StudentsStudents

General General PopulationPopulation

%%YesYes

Don’t Don’t knowknowDon’t Don’t

knowknow

*p<0.01*p<0.01N=290N=290 N=580N=580

**

Overconfidence Among Medical Students in Overconfidence Among Medical Students in Ethical QuestionEthical Question

Overconfidence & Assertiveness Overconfidence & Assertiveness Are Detrimental to Critical Are Detrimental to Critical

Professional AbilitiesProfessional Abilities

Admit “I do not know”Admit “I do not know” Tolerate uncertainty & ambivalenceTolerate uncertainty & ambivalence Respect patient’s & family’s viewsRespect patient’s & family’s views Team workTeam work Admit error/suboptimal performanceAdmit error/suboptimal performance Ability to change & improveAbility to change & improve

A potential solution might be in granting A potential solution might be in granting students, early on in the curriculum, students, early on in the curriculum,

responsibilityresponsibility for patient care, aligning for patient care, aligning pedagogic and professional goals.pedagogic and professional goals.

Early clinical experience with suffering, Early clinical experience with suffering, disease and death, will expose students disease and death, will expose students to values such as empathy, caring and to values such as empathy, caring and

responsibility to the other - fundamental responsibility to the other - fundamental steps in finding existential meaning.steps in finding existential meaning.

Brezis M. Caring in medicine: missed opportunity for healing? J Eval Clin Pract 2009:990-2Brezis M. Caring in medicine: missed opportunity for healing? J Eval Clin Pract 2009:990-2

Conceptual Solution to CheatingConceptual Solution to Cheating

ConclusionConclusion

Education for Education for professional professional

values during values during medical school medical school deserves a new deserves a new

paradigm. paradigm.

Medical students disclose problematic Medical students disclose problematic attitudes and behavior related to attitudes and behavior related to

honesty, lifestyle & overconfidence. honesty, lifestyle & overconfidence.

Dad, I’m considering a career in organized crime

Government or private sector?

Thanks to Ms. Lois Gordon Thanks to Ms. Lois Gordon for graphic assistancefor graphic assistance