AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2005, Volume 7, Number 4.

Clinical Cases

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A Case of Student Cheating

Medical students must accept responsibility for upholding their own individual code of professionalism based on universal standards of ethical behavior.

Commentary by Veronica Catanese, MD, and Paul Aronson

Joe is a motivated first-year medical student who managed to score close to the class mean on all of his tests during the first semester. During the first exam of the cell biology course, Joe found himself distracted by the movements of a classmate seated 1 row ahead of him. He noticed that Danielle was repeatedly taking out her cell phone, looking at the screen, and slipping it back into her pocket. Occasionally, she punched on the keys before putting the phone away. Intrigued by what she is so busy with, Joe craned his neck to get a look at the cell phone screen. On it he reads,

17D18E do u no 19?

Joe watched Danielle hit the send button and slide the phone back into her pocket. Stunned by what he had just seen, Joe tried to concentrate on finishing his test, but he could not help noticing that Danielle's text-messaging dialogue continued for the remainder of the exam, and he watched her exchange answers with the recipient of her text messages several times. Joe felt disappointed and a little angry to be burdened with this knowledge.

Joe later learned from other members of his class that the Deans' Office had already been made aware of cheating amongst several students. As part of the Deans' investigation, an email was sent out to the student body encouraging students to report the names of specific wrongdoers. Joe did not know what to do.

Commentary 1

by Veronica Catanese, MD

Just as fiction draws heavily on reality, we often draw on actual experience to devise hypothetical cases for educational purposes. Joe and Danielle are not figments of a medical student's imagination. They are pseudonyms for real students; the details of their story have been changed, but the core issue remains the same. Last year, more than 1 member of New York University's second-year medical class reported witnessing technologically assisted cheating by Danielle and her cell phone buddy and more than 1 member of the class made the Deans' Office aware of that cheating and volunteered the identity of Danielle. But not a single member of the class spoke with Danielle before reporting the incident to the Deans' Office. Not a single member of the class agreed to shed anonymity or, even in a mediated environment, discuss his or her concerns in Danielle's presence.

Like history, experiences in our own lives tend to repeat themselves. Just 1 week after learning about Danielle, I heard a similar story from my own daughter, a college freshman. Part of the learning process in her chemistry course involved peer review of her laboratory report draft by another student in the same lab section. Each student was required to post electronically and exchange, over a 48-hour period, his or her draft with an assigned review partner; the final copy of each student's lab report, a version that presumably incorporated the review partner's suggestions for improvement, was due to the laboratory preceptor after an additional 48-hours. My daughter posted her report; a day later, when she received the first draft of her review partner's report, she noticed that entire paragraphs of his report were virtually the same as those she had written. This time, I was not one of the deans; instead, I was the mother and, fortunately enough, someone whose opinion my daughter sought and trusted. Should she speak with the student, speak to the lab preceptor, or do nothing at all? I recommended that she speak with her review partner, point out directly that portions of the 2 reports were very much alike, and suggest that she'd be happy to review the next version of his report as soon as he'd re-worked it. A day later, she received a second version of his lab report, along with a note thanking her for pointing out how similar both original versions were.

What were the expectations of the students who had observed these 2 breaches of honesty and professionalism? Here at our medical school, the students who came forward to the Dean's Office with the allegations against Danielle and her friend were not willing to confront them personally. Instead, they expected 1 of 2 things: either that we, the deans, would call in Danielle and her friend and confront them with the cheating allegations or, as the next best alternative, we would send a letter by email, to the student body restating that any form of dishonesty and cheating would not be tolerated. We responded that there was absolutely no need to restate the obvious: dishonesty and cheating in any environment, at any time, under any circumstances, completely undermines professional behavior; that anyone at all, let alone our white coat ceremony graduates, could possibly think otherwise was simply unacceptable. Although the deans did not write such a letter, a few of our student government leaders did. Student tension over the issue eventually dissipated, and no further allegations were made. But was the ethical and professional dilemma resolved? I think not.

My daughter's expectations of me were not very different from those of our medical students. In fact, her expectations were similar to those that many of us have when confronted with a problem we'd rather not face—she wanted me to tell her what to do. The medical students' expectations were the same—they wanted others to do what they themselves would rather not do or, alternatively, they wanted to apply a band-aid to the problem and hope that it would disappear. The outcomes of these 2 scenarios were quite different, however, because of 1 critical factor: acceptance of responsibility. Danielle's colleagues were not willing to accept the responsibility of confronting her with their observations. As a result, Danielle was denied the chance to address the issue, work to resolve it, and sustain true professional and personal growth as a result of the experience. My daughter's response (which, by the way, came only after much angst and plenty of tears) was facilitated by 2 things: her having signed, and feeling responsible to uphold, an explicit honor code at the beginning of the school year, and my having experienced, from a different perspective, a similar dilemma and having thought carefully and critically about the ethical course of action and outcome.

No one would argue that cheating on assessments of knowledge is blatantly unprofessional; the scope of professionalism in medicine, of course, is far broader. My purpose is not to paint the enormity of that landscape but, rather, to put forward for your consideration what may be the central dogma that unites all aspects of professional behavior—that acceptance of responsibility is the non-negotiable requirement for ethical behavior. Furthermore, responsibility cannot be accepted anonymously, not in the context of a patient-physician or colleague-colleague relationship and not when it affects another's health and welfare, our own health and welfare, our own personal and professional growth, or the continuous growth and professional development of others. It is simply not enough to report or export a breach of professionalism—we are also bound to actively and directly promote the positive resolution of that concern. Without that level of personal responsibility on each professional's part, professionalism will remain a fictional ideal, and never become a reality.

Veronica Catanese, MD, is an associate professor of medicine and cell biology and senior associate dean for education at the New York University School of Medicine. She is a member of the Institute of Medicine's Clinical Research Roundtable and chair of the NIH study section on bioengineering and physiology.

Commentary 2

by Paul Aronson

Two worlds with different expectations collide in medical school. On one hand, medical school is exactly what its name states, a "school," whose enrollees are students, as most of them have been for the great majority of their lives. They are not yet in the professional world. While this does not absolve them of acting unprofessionally or of conducting themselves with less than the utmost integrity, society does expect less of students than it does of "professionals," in this case practicing physicians. As medical students, we are expected to display limited medical knowledge in the hospital, to make the incorrect diagnosis most of the time, and to be dependent on more experienced medical personnel for the majority of our decision making. As a result of these expectations we have multiple layers of support in the classroom and on the wards. Hence, we assume that our judgment in other aspects of life is not held to the same standards as those in the "real" world.

The other world that we inhabit in medical school—the world of doctors-in-training—demands the highest professional standards perhaps of any vocation. We are studying to be doctors, and during our 4 years in medical school we interact with and treat real patients. Patients often consider us to be their actual physicians, ignoring the length of our short white coats or the term "medical student" written on our identification badges. Within this world, we are held to the same professional standards as house officers, attending physicians, and professors emeriti. And these expectations dictate that we act with honesty, integrity, and the utmost respect for professionalism.

Therefore, when we are asked by our Dean's Office to report the names of our colleagues who are cheating, we are faced with the discordant expectations of our 2 worlds. We take exams in a room patrolled by proctors, whose duty it is to ensure that no student is cheating, and we assume it is their responsibility along with the course directors and the Dean's Office to handle breaches of professionalism should they arise. After all, that is the way it has been in our other schools and we are still simply students.

Challenging the label "simply students" is the fact that we are enrolled in a professional school and expected to conduct ourselves with honesty and integrity. As physicians, we will be responsible for patients whose health and lives are in our hands, and it will be our duty above all else to ensure their well-being. This duty confers upon us responsibility not just for our own actions, but also for those of our colleagues. A fellow physician who conducts himself in an unprofessional manner may negatively affect a patient, and the code that implores physicians to "do no harm" mandates that we take the initiative to confront that colleague. Moreover, this responsibility begins not when we step into the hospital as interns, but when we step into medical school as first-year students. It begins when we are given our white coats and asked to recite our physician code of beneficence and nonmalevolence. It makes no sense to permit unprofessional behavior throughout medical school and expect graduates to begin conducting themselves professionally on the day they become interns. Professional behavior—like recognizing disease symptoms, understanding treatment, and talking to patients—must all be learned in medical school.

So, at some point in year 1 or 2, we find ourselves requested by the Dean's Office to report our cheating classmates. It is easy to say that each of us has a responsibility to ensure that the code of professional conduct is adhered to by all students, but it is far more difficult to report a classmate's name. While one can justify silence by saying, "It's just an exam, it doesn't mean anything," remaining silent may allow the 2 students to get through medical school by cheating—and with significant gaps in their knowledge. Even worse, perhaps they will continue this behavior on the wards, and lie about a lab value or a physical finding. Then it will not be just an exam, but possibly a patient's life.

Ultimately, each of us must live up to his or her own individual code of professionalism that incorporates these universal professional ideals. The goal of a professionalism committee is to create an environment that facilitates our development of a standard of professionalism. Our particular medical school's honor system or professionalism committee is intended to provide us with guidelines that should be followed, and in a given situation we must act with these in mind while making our own decision. Thus when we graduate and become practicing physicians in 4 short years, we will each carry with us our individual professional codes developed through these universal standards, but of which we have full ownership. It will not be a code forced into our conscience, but rather a system of principles that we each developed with the facilitation of our medical school.

Paul Aronson is a fourth-year medical student at the New York University School of Medicine and a future pediatrician.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.