AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. May 2009, Volume 11, Number 5: 368-372.

Clinical Cases

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Competitiveness Can Undermine Team Goals

Competitive behaviors can undermine a clerkship studentís residency goals and weaken team collaboration and communication.

Commentary by Jeffrey Reagan, MD, and Laurel C. Blakemore, MD

Adam and Emmett had just finished their third-year clerkships and were doing their first elective. Both had chosen orthopaedic surgery, hoping eventually to be selected for a competitive orthopaedic-surgery residency. Adam’s heart had been set on becoming an orthopaedic surgeon for quite some time. He had grown up with an orthopaedic surgeon as a father, and he remembered a conversation with his dad right before he started medical school that, in retrospect, had been a real turning point in his life. His dad had said he would be proud to have Adam join his practice. It was the first time his father had said anything like that. They had talked about it off and on in the years since then, and Adam had grown increasingly interested in the idea of doing orthopaedics and joining his dad’s practice, knowing it would mean a comfortable life.

Learning Objective Identify competitive behaviors that can undermine a clerkship studentís residency goals and weaken team collaboration and communication.

Adam received good clinical grades, scored above average on USMLE Step 1, and continued to develop an interest in orthopaedic surgery. The pressure to do well on the orthopaedic rotation, get a good letter of recommendation, and rank among other well-qualified applicants prompted Adam to become increasingly competitive.

He began arriving before Emmett in order to pre-round on both his and Emmett’s patients, hoping that he would be able to answer a vital question if Emmett faltered. Adam was initially disturbed by his increasing willingness to be so competitive, especially at the expense of another student. But, over time, he grew accustomed to it, driven by the prospect of joining his father’s successful practice. He reasoned that surgery was difficult, and the competitive culture actually benefited patients; it meant more people were being attentive to the details of each case. He wondered if he was upsetting Emmett, but told himself that Emmett was free to be just as competitive and that, in the end, the harder working, more deserving student would be selected to an orthopaedic residency spot and make a better surgeon.

Commentary 1

by Jeffrey Reagan, MD

The task of securing an orthopaedic-surgery residency or any competitive residency position can be difficult and nerve wracking. With increasing enrollment into medical schools and relatively few orthopaedic-surgery residency training positions, prospective students must find ways to stand out from the crowd. This is not a new concept for students; it is not unlike the process of being accepted into medical school. Candidates must have excellent medical school grades and USMLE Step 1 scores and show exceptional interest in their prospective fields. Research in orthopaedics, including publications, is expected. Extracurricular involvement, volunteer experiences, and leadership experiences are required. High performance on clinical rotations is crucial for acquiring good recommendation letters and ultimately interviews for competitive residency positions. A deficiency in any of these areas may result in a failure to match into orthopaedics.

Residency programs must choose candidates wisely to balance surgical training with effective patient care. When a residency program admissions committee identifies a profile of its ideal candidate, that person is most likely intelligent, teachable, enthusiastic, and professional. Good ways to measure these attributes are by performance on clinical rotations and by letters of recommendation, which give programs an idea of how a candidate will perform as a resident.

In this case, Adam’s motivation to become an orthopaedic surgeon is clear. He looks forward to the prospect of joining his father’s practice and has excelled in his first year of clinical rotations. It seems that he is on track to achieve his goal by receiving good grades, scoring well on USMLE Step 1, and doing his best on his orthopaedic clerkship.

Driven by his nervousness about his orthopaedic clerkship performance and his desire to join his dad’s practice, Adam finds himself increasingly competitive, turning to “one-upping” Emmett and arriving early to pre-round on all the patients. Adam has justified these actions by incorrectly assuming that they are what make a good surgeon and that they will benefit patient care [1]. He further rationalizes that his tactics are acceptable because Emmett could do the same if he chose to work as hard.

Adam has fallen prey to an all-too-common misconception of surgical training and medical education. Perhaps this should not be surprising: who hasn’t heard a story about a narcissistic surgeon? The idea that competition has to be cutthroat with a “take no prisoners” attitude, however, is foolish and counterproductive to the team approach of medical care. Current medical care is complex, requiring specialized health professionals and the need for these professionals to collaborate and communicate effectively [1-3]. This may be particularly evident in surgical-training programs, where students and physicians with different levels of knowledge and experience interact to provide patient care both on the floors and in the operating room. Self-serving behavior like Adam’s does not benefit patient care, and could anger Emmett, which would lead to a breakdown in team communication.

It is foolish for Adam to think that his poor behavior will go unnoticed. The residents he is working with have overcome similar challenges in their surgical training and may not appreciate Adam’s antics. News of his actions may even find its way to attending surgeons who will be wary of introducing a potentially destructive element into their residency programs. Adam’s behavior will almost undoubtedly backfire. Interestingly, Adam himself was initially disturbed by his actions. This should be a good guide that his behavior misses the mark.

If Adam is lucky, the residents he works with will offer constructive feedback about his behavior. I personally would tell Adam that his willingness to work is excellent, but there are better ways to stand out that are not at Emmett’s expense. I would direct Adam to focus on his own assigned patients and all aspects of their care including the diagnosis and classification of injury, different types of surgical treatments, postoperative care, and physical-therapy needs.

Adam’s behavior will also affect Emmett. There are many ways that Emmett could react, but his best course of action is to discuss the situation early on with Adam. It is reasonable to think that with a cooperative effort both can excel in the rotation.

Medical students strive to stand out from an already exceptional crowd. Despite Adam’s example, this can be done while maintaining integrity and professionalism. A competitive environment can motivate one to exceed expectations. On the other hand, it can cause some students to resort to underhanded tactics in an effort to differentiate themselves from their competitors. Hard work and an interest in the field are a good start, but they are not enough. Becoming a well-rounded candidate is also necessary, and this requires developing communication and leadership skills. A hypercompetitive attitude will undermine these aims. Adam and other medical students applying for competitive residencies should work to stand out individually while maintaining a team-player attitude.



References

  1. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ. 2006;40(11):1098-1104.
  2. Swick HM, Szenas P, Danoff D, and Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA. 1999;282(9):830-832.
  3. Sargeant J, Loney E, Murphy G. Effective interprofessional teams: “contact is not enough” to build a team. J Contin Educ Health Prof. 2008;28(4):228-234.

Jeffrey Reagan, MD, graduated from Saint Louis University School of Medicine and is a second-year orthopaedic surgery resident at Saint Louis University.

Commentary 2

by Laurel C. Blakemore, MD

How far should medical students go to acquire the accolades that they think will assure them a residency slot in a competitive specialty? I approach this question from two different but related perspectives: that of a program director in orthopaedics and that of a surgeon interested in ethics and professionalism.

There is nothing inherently wrong with Adam’s wish to pursue a career in orthopaedic surgery and join his father’s practice. Students commonly follow a parent or mentor into the medical field and may have an advantage when they do so—first-hand knowledge of the pros and cons of a given specialty and its associated lifestyle. Although this scenario implies that Adam is pursuing orthopaedics primarily to please his father and join a financially lucrative practice, those motives are not certain; nor are they unethical—but they are probably not going to guarantee Adam a satisfying career. Orthopaedic surgery can be highly rewarding but it’s hard work, both during and after residency training, and one must have a real interest and dedication to be happy and successful. There are many paths to financial success that are less demanding than orthopaedic surgery, and (fortunately) most people come to that realization before entering a training program.

As a program director, I would be unhappy to hear about Adam’s conduct on the service. Orthopaedic surgeons place great value on teamwork and the ability to enhance the function of a team, so Adam’s behavior would be seen for what it is: an attempt to make Emmett look bad. Residents in particular can quickly identify medical students who engage in this kind of behavior [1, 2]. Adam’s argument that this sort of competition benefits patients doesn’t justify his actions. Rather than rounding on Emmett’s patients in hopes of showing him up on rounds, Adam should spend his efforts finding ways to help the entire team take better care of the patients. The team’s function is to provide excellent care for patients through attention to detail, compassion, and communication. The team must also work efficiently and accurately. Students who can improve the team’s performance are valued; those who give the impression that their purpose is to show themselves in the best light at another student’s expense are not.

There is nothing wrong with competition per se. The American Academy of Orthopaedic Surgeons (AAOS) Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery states that “competition between and among surgeons and other health care practitioners is ethical and acceptable” [3]. At the same time, choosing a career in orthopaedic surgery solely for financial gain violates our standards of professionalism, which emphasize that “the orthopaedic profession exists for the primary purpose of caring for the patient” [3]. A surgeon must be able to make decisions in the best interest of the patient regardless of potential financial gain.

Orthopaedic residency is highly competitive, and those who thrive on competition are often successful professionally. Competition may contribute to a surgeon’s motivation to maintain clinical productivity, stay current with continuing medical education, and excel in a given area of interest. Nevertheless, the Guide to Professionalism must direct an individual’s conduct, keeping patient well-being paramount in all professional actions. The same principles apply to medical students and residents. Competitiveness becomes harmful when it drives a trainee to show himself in a favorable light at the expense of other team members. Striving to deliver the most conscientious care you can, be as well-prepared for cases as possible, and help teammates perform their duties are all productive means for competing for favorable evaluations while adhering to aspirational ethical standards. This is what program directors want to see in a prospective resident, because those who demonstrate these values will generally be strong residents and successful orthopaedic surgeons.


References

  1. Evarts CM. Resident selection: a key to the future of orthopaedics. Clin Orthop Relat Res. 2006;449:39-43.
  2. Thordarson DB, Ebramzadeh E, Sangiorgio SN, Schnall SB, Patzakis MJ. Resident selection: how we are doing and why? Clin Orthop Relat Res. 2007;459:255-259.
  3. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. 8th ed. 2008. http://www.aaos.org/about/papers/ethics/ethicalpractguide.pdf. Accessed April 14, 2009.

Laurel C. Blakemore, MD, is chief of the Division of Orthopaedic Surgery and Sports Medicine at Childrenís National Medical Center in Washington, D.C., with expertise in pediatric spine surgery. She specializes in treating children with scoliosis and spinal deformities, as well as in adolescent sports medicine and pediatric trauma. Dr. Blakemore has served on many national committees for the Scoliosis Research Society, Pediatric Orthopaedic Society of North America, and American Academy of Orthopaedic Surgeons and has published numerous articles and book chapters. She was selected as an AAOS leadership fellow in 2004 and hosted the SRS International Travelling Fellows.

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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.