Medical School: Your Learner’s Permit to Licensure

By Thomas N. Told, DO, FACOFP dist., Dean of RVUCOM

While a learner’s permit provides a great opportunity for new drivers, it also comes with a much greater responsibility to public safety. In the case of the medical student, they are learning to be trusted with one of the most responsible and coveted professions in America. As such, students are not just learning to operate any vehicle; they are learning to operate a high-performance racing vehicle or the unrestricted medical license. If not operated properly, it can do great harm to those who need treatment and to a student’s career and livelihood.

It is important to develop best practices early on in the relative safety of a medical school training environment before hitting the road towards real-time patient care. Just as racecar drivers train on a safe field with fire and emergency suppression close at hand, medical schools are equipped to detect and hopefully mitigate dangerous habits and behaviors. As a medical student, remember that you will be a student driver during the four years of medical school, so be patient, listen, and learn.

Medical students will be judged at a higher standard. There is no tolerance for error or bad behavior. Those who shun excellence will not succeed. In medical school, you will be given unique privileges to interact with and participate in the treatment of patients. This includes knowing his or her innermost fears and secrets in a way no one else does.

You will also be expected to function as an effective member of many different health care teams and must abide by the “physicians in training” laws of most state medical boards. However, the public expects you to act like a physician (even if you are not one yet), and that encompasses the way you present yourself, be it your appearance, habits, professionalism, social mores, and the way you communicate. You will live every day in the same “glass house” that all physicians live in, regardless of your year in school.

Medical students, and the profession as a whole, are held to a higher standard of professionalism. As physicians in training, you are dedicating yourself to the service of humanity. Professionalism will take the form of encouraging positive peer relations, appropriate presentation at clinical encounters, being on time, and respecting those who teach you the art of medicine. Professionalism is aspiring to an ideal and constantly reflecting on that ideal.

Alternatively, a lack of professionalism is one of the biggest reasons for dismissal from medical school or discipline by medical boards. Poor initiative and a diminished capacity for self-improvement have been identified by the Federation of State Medical Licensing Boards as predictive of physicians who will have issues with medical boards in future practice. Other hallmarks of a lack of professionalism are honor code violations, substance overuse or dependence, and boundary issues.

Your evolution into a strong and effective physician that will care for all of humanity is a lifelong endeavor that is never finished. In the words of Sir William Osler: “The hardest conviction to get into the mind of a beginner is that the education upon which [he or she] is engaged is not a college course, not a medieval course, but a life course, for which the work of a few years under teachers is but a preparation.”

Criticism of a fellow medical professional in clinical practice is referred to as “jousting” and is always considered unprofessional conduct. Jousting behavior, which can start as early as medical school on course evaluations and in communications, can raise malpractice rates or even cancel malpractice insurance. Such behavior can also land you in the witness chair or get you sanctioned on a hospital staff.

Jousting includes anonymous comments on evaluations that are not constructive, do not offer helpful suggestions, and may be outright attacks. Below are examples of this:

“Dr. _____ is a pretty good teacher. However, he/she’s a huge, arrogant jerk. On multiple occasions, myself and other students would ask questions and he/she would always have some backhanded comment about how stupid we were. Even when we were answering his/her questions correctly, he/she tried to keep us going until we got something wrong, all so he/she could make fun of us. Great teacher, awful human being.”

“Big Indignant Tirade Castigating & Hateful (‘BITCH’) – by far one of the most incompetent professors at this institution. I am rather disappointed and frustrated that a medical school would hire a lecturer who admits not fully understanding the material. She lectures as if we are high school students.”

When giving opinions, even if it is anonymous, follow these simple guidelines:

• Be truth-seeking. Don’t shoot from the hip or out of anger. Ask for reasons and evidence in pursuit of the best knowledge.
• Be open-minded. Be tolerant of diverse points of view. Everyone has something of value to contribute; you just have to listen.
• Be analytical. Consider the consequences of actions (or inaction). It helps to sometimes think of it as: “Would I like to have my actions or statements in the news.”
• Be systematic. Create a habit of taking an organized approach.
• Be confident in your reasoning. Rely on well-reasoned judgment and give constructive suggestions.
• Be inquisitive. Ask “why” and “how come” and always taken an interest in learning.
• Be mature in your judgment. The high road is always the best road and usually the one with the fewest ruts. Make a habit of making timely and thoughtful judgments.

For a final story about the value of professionalism, I will turn to John Grisham, whose novels I love because he points out the flaws and foibles of the legal profession. In the book The Rainmaker, a young lawyer takes on a predatory insurance company that has made a fortune by denying claims to clients. In the film adaptation, the lawyer’s client had been denied multiple times by the company and was issued an unprofessional and disrespectful letter. The denial letter was read in court. The judge ruled that each time the word “stupid” was mentioned in the letter, the insurance company was fined $16.6 million dollars. Click here to watch the clip.

Finally, consider this quote, borrowed from the ethics paper of one of your own classmates: “I will choose my words carefully, knowing they greatly affect others.”