Mark shuffled behind Dr. Powell, furiously writing out the LaFarge equation for estimating oxygen consumption on his clipboard. As usual, he had embarrassed himself while presenting the previous patient after forgetting to do the basic cardiac calculations before rounds. He promised himself he wouldn’t forget it again.
Mark’s pediatric cardiology clerkship, now only in its second week, had been the worst of his clinical years. Cardiology had never been his strong suit. During the first week, Mark’s struggle with interpreting blood gas results and repeated confusion of VSD with ASD had made it apparent that he was the weakest of the five clerkship students.
Today, however, none of his peers were having luck with Dr. Powell’s relentless pimping. Dr. Powell was a decent teacher, though his reliance on that particular teaching tool made every morning miserable.
“Mark, maybe you can do better than your colleague.” Mark snapped to attention. Dr. Powell had begun questioning the group about the next patient. Mark was standing second in the line of students outside the room. His colleague to the left of him looked distraught, fumbling in his notes for the answer to the question he just missed. “Based on the echocardiogram, what kind of congenital defect should we be looking for?”
“Uh,” Mark stuttered. He had viewed the imaging study for this patient before rounds this morning, but he was always terrible at septal defects. “Is it an ASD?” Mark answered tenuously.
“Jesus, Mark, have you learned anything in school?” Dr. Powell barked at the top of his lungs. “I can’t believe you’re even in the same class as these guys! At this rate, the only good thing I’ll be able to do is fail you from this clerkship. Go the library and do not come back until you know what you’re talking about.”
Mark was stunned. Hadn’t the other guy missed the same question? Out of the corner of his eye, Mark saw his colleague’s shocked expression turn into steeled discomfort as he suddenly faced forward. Dr. Powell stared at Mark expectantly. Taking the hint, Mark turned away and started towards the end of the hall as the pimping continued behind him.
Nurses at the charge station at the end of the hallway looked at him sympathetically; they had heard the tirade all the way at the end of the ward. Staring dejectedly at his feet and hating every stupid neuron in his head, Mark literally ran into his colleague Jarna on her pediatrics rotation, tripping over her neon orange clogs.
She put her hand on his shoulder, looked at him straight in the eye, and said, “Suck it up, dude. This is medical school.”
Thomas Nagel, famous twentieth-century philosopher, writing about the ethics of war, not the pimping of medical students, formulated the rule that we should all be Kantians (he uses the word “absolutists,” but the thinking is the same) in our ethics, except when it is too difficult . Let me first explain what Kant would advise, and then we need to ask whether his recommendation carries too heavy a penalty to be realistically expected.
Kant believed that the best way to determine the ethical choice in a circumstance is to do a thought experiment in which the behavior you are considering is universalized . In other words, he asks that you ask yourself whether you can conceive of a world in which everyone must do what you are considering doing. Your one action would become as binding as a law of nature. So, he argues, lying is immoral by this standard, because if universalized it would be self-defeating: if everyone lied, no lie would be efficacious in achieving its desired end. Kant isn’t worried about the effectiveness of lying; rather, his thought experiment is supposed to help you determine whether your action is rational or not. Lying presupposes the existence of truth telling because you cannot deceive people unless they expect that you are telling the truth. But if lying becomes a universal law (everyone must do it), then no one would be able to believe anyone else; the law becomes self-defeating. Kant believed that looking at each decision in this way could help us make moral choices, and that such choices would affirm human dignity and make the world a better place.
How does Kant’s reasoning apply to this case? Mark has a simple choice—report the inappropriate, verbally abusive behavior or do nothing. Universalize both choices, and decide which leads to a world you would want to live in. Obviously, reporting the behavior promotes human dignity, whereas ignoring it places Mark’s grade in pediatric cardiology over the larger good of holding attending physicians accountable for their behavior toward medical students.
But if this part of the decision is easy, the second part is not. Must we always be good Kantians? Even though Kant is concerned with duties, not consequences, Thomas Nagel thought that sometimes the consequences of “doing the right thing,” from a Kantian perspective, were just too great to be upheld in every instance . However, I don’t think that is the answer we should reach in this case. Mark is struggling in this clerkship, and, if Dr. Powell is his primary attending, his grade is going to be a problem whether he reports him or not. In fact, by reporting him, he may be able to convince the dean to disqualify Dr. Powell’s evaluation from his final grade. This is uncertain, so I am not arguing that he should report him out of self-interest, only that his interests may not actually be harmed by doing so.
The unknown aspect is how a report will be received. If Dr. Powell has already been reported as abusive, then Mark is likely to be believed and potentially protected from his report. If Mark is the first to report, things are less certain; he has no way of knowing whether his fellow students have also “done the right thing” and reported Dr. Powell. If they have, these reports will protect Mark from reprisal and move Dr. Powell one step closer to the door.
How are we to understand Dr. Powell’s actions from within this same framework? I see only two reasonable possibilities, and they are both damning in different ways. The first option is that Dr. Powell believes that his teaching method is appropriate and efficacious. That is, embarrassing students is an acceptable way to “raise the bar” and encourage them to achieve. If he believes this, he has failed to educate himself regarding the evidence. Research has unequivocally shown that creating a hostile, intimidating environment is antithetical to learning skills and professionalism [3, 4]. So, if Dr. Powell believes he is a good instructor, he has failed to approach his duty as a teacher with the same evidence-based methods that he presumably applies to his specialty.
The other possibility is that he doesn’t actually care about the quality of his teaching or, worse, that he enjoys making people subordinate to him feel bad. There are many possible variations here: he may be repeating bad behavior exhibited by his mentors while he was in training, he may enjoy his power and be a bit sadistic. The psychological analysis is, from an ethical perspective, unnecessary because his behavior hinges on a choice again to prioritize himself over the needs of his students. At best he is placing his clinical responsibilities over his teaching duties; at worst he is hurting others intentionally to satisfy some inner need or desire.
My point is that, although we cannot know his motives with any certainty, there is really no way to ascribe any positive motive to his behavior (unless you think it is positive to be willfully ignorant of the research on a major aspect of your profession). Kant argued that we should be cautious in our judgment of others and always seek to give them the benefit if the doubt. I believe the most generous reading of Dr. Powell’s behavior is the first possibility: ignorance of the harm and ignorance of good teaching methods.
This leads us back to the question of what Mark should do and reinforces our original answer. If Dr. Powell has simply not paid attention to what constitutes good teaching, and once made aware of his failings would seek to improve, then Mark benefits both future students and Dr. Powell by making the dean of the medical school aware of his failings. But if Dr. Powell is actually working from darker motives or character flaws, then the sooner he is removed from a teaching position, the better.
- Nagel T. War and massacre. Philos Public Aff 1972;1(2):123-144.
Kant I. Groundwork to the Metaphysics of Morals. Abbott TK, trans. Radford, VA: A & D Publishing; 2008.
- Shrank WH, Reed VA, Jernstedt GC. Fostering professionalism in medical education. J Gen Intern Med 2004;19(8):887-892.
- Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med 1998;73(11):1149-1158.