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 2007, Volume 9, Number 4: 277-279.

Clinical Cases

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Self-Interest versus Friendship in Medical School

No clinical consensus exists about when to intervene in hyperkalemia, a common electrolyte imbalance complicated by the recent increased use of medications for hypertension that affect the renin-angiotensin-aldosterone system.

Commentary by Deirdre Masterton, MD

Joe and Mary were friends and classmates on their third-year clerkship in obstetrics-gynecology. Mary had known for a while that she wanted to go into ob-gyn, and she hoped to make a good impression during her brief time in the clerkship. Joe liked ob-gyn too, but was still undecided about what field he wanted to pursue. Throughout the clerkship, Mary made a point of scrubbing in for surgery at every chance—which sometimes meant that Joe could not. Several of the procedures she observed were particularly instructive, including an emergency tubal resection following a ruptured ectopic pregnancy.

Joe scrubbed in on half as many surgeries as Mary. He was relegated to following the more routine cases and had to do a disproportionate amount of "scut" work on the floors. The residents and attending physicians were too busy to notice the discrepancy. Joe learned a lot on his rotation, but he felt somewhat shortchanged and thought that Mary acted inappropriately. At the end of the rotation, Joe and Mary sat down to exchange feedback on their experience working together as part of the clerkship's professionalism evaluation. Joe was ambivalent about whether to confront his friend, thinking perhaps it was his fault for not being assertive enough. Even if it was her fault, Joe thought to himself, "I don't want to jeopardize our friendship and make a big deal of this." He decided simply to praise Mary for her enthusiasm and wish her good luck with her plans to apply for an ob-gyn residency.

Commentary

By nature, most medical students are high achieving, bright people who are goal-oriented and hooked on performing well. Students progress through the first two years of medical school in the isolation of the library, toiling over books, notes and transcripts. Then, one July morning, clinical clerkships begin and demand a completely different skill set than the one that earns A's in the classroom. Now, performance evaluations often depend more on interactions with patients and colleagues than on retention of facts from reading and lectures. There is no class that teaches etiquette within a team or how to get the most out of a clerkship. For the first time, students must relate with colleagues and peers to navigate this exciting period of training successfully.

Mandatory feedback sessions are staged encounters at the end of clerkships, intended to offer colleagues an opportunity to practice formulating and receiving constructive critique. Often those conversations address sensitive topics including how colleagues function within a team and how they relate to patients or other team members. The idea is to develop effective language and communication skills in a protected situation, so that, eventually, coworkers will exchange candid and comfortable evaluations of peers during daily work encounters.

Medical school professional relationships frequently develop in the context of pre-existing personal relationships formed during the preclinical years. On the wards, friends become team members, and a new interdependence develops that did not exist in the solitude of preclinical study. This interdependence affects student experiences and exposure to a given field, as in the case of Joe and Mary. As training progresses and clinical responsibility grows, the interdependence of colleagues becomes more profound. Provision of efficient, quality care to patients demands the best performance from everyone. Consequently, members of a health care team must maintain open communication with one another and must constantly exchange ideas and feedback, good or bad, to ensure that patients are treated properly and that everyone is putting forth his or her best effort.

The busy work schedule allows for development of close personal relationships with colleagues, yet these friendships must not interfere with achieving work-related objectives. Effective communication and feedback strategies are a learned skill set, and the sooner the skills are developed, the better prepared a clinician is to know when to speak up—and when to keep thoughts private.

Identification of moments or situations that demand collegial feedback is subjective. What's sought is a balance between avoidance of confrontation and compulsive nitpicking. Each person must consider the potential problems caused by a behavior and weigh them against the anxiety created by confrontation and the potential effect the feedback may have on working relationships.

Behavior is most easily modified if missteps are identified immediately and addressed privately and concretely and if more acceptable behaviors are modeled and applauded. That said, artfully confronting a friend's misbehavior in a respectful way, in the moment, takes confidence and practice. Retrospective feedback feels safer. It can be carefully crafted and properly "sandwiched" or even provided in writing to try to lessen the humiliation of the recipient. Unfortunately, hoarding critique until the end of a rotation denies a colleague the opportunity to learn from her missteps and to prove to the evaluator that she is capable of better. Sadly, Joe may not have an opportunity to work with Mary again after this feedback session and will not get to recognize and applaud her changed behavior.

By not offering truthful and complete feedback to Mary regarding what Joe perceives as inappropriate selfish behavior, he shortchanges both Mary and himself. This particular issue is a perfect opportunity for Joe to practice constructing meaningful criticism for a colleague with little risk. Joe should force himself to provide an honest critique of his friend's performance and develop the skills necessary for such a conversation. Once the language skills are in place, he will find exercises like this much more comfortable. More importantly, if in the future Joe encounters a colleague whose behavior poses danger to patients or to that colleague, he will feel empowered to address the situation directly.

By not expressing his frustration with Mary's self-serving behavior on the ob-gyn rotation, Joe may be allowing his friend to continue her behavior in subsequent rotations, upsetting her teammates and compromising her work relationships. Joe is her friend and is obviously aware of Mary's feelings. It is better for her to hear this from him now, in a sensitive way, than in the future from a frustrated colleague who has less concern for Mary's self-esteem. Joe should recognize the opportunity to be altruistic—Mary's changed behavior may never benefit him directly—and let her know how she can be a better team player.

Ideally, Joe would have addressed his friend's unacceptable behavior earlier in the rotation, using concrete examples of specific behaviors that compromised their working relationship and suggesting more acceptable alternatives. Admittedly, successful pursuit of this course of action requires confidence, courage and a specific skill set. Lacking these skills, Joe should have identified the planned feedback session as a chance to practice offering constructive criticism to his friend on this point. That choice might have afforded him the opportunity to observe Mary's response in this protected environment. Because Mary is his friend and they were required to have this conversation, he could have asked for candid feedback from her on how he delivered his commentary. If Joe had been honest in the feedback session, and addressed his concerns directly with Mary, both students would be better prepared for their next (inevitable) conflict with a colleague at work.

Deirdre Masterton, MD, graduated from New York University School of Medicine in New York City, and is a third-year obstetrics and gynocology resident at Women & Infants Hospital in Providence, Rhode Island.

Medical student professionalism education at New York University School of Medicine, April 2007

Peer feedback, April 2005

Giving honest feedback, August 2005

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.