Saturday, June 6, 2015

Academic Dishonesty as a Medical Student - How Prevalent? What Does the Future Hold for Them?

Earlier this evening, a media ‘exclusive’ was published in the Sydney Morning Herald.  The article is about my own institution, The University of Sydney.  This was a huge shock. This is the place where I was an undergraduate medical student and now the place where I am an academic surgeon who is intimately involved in hands on teaching of medical students.

The article makes the claim that students have been cheating in their Integrated Population Medicine assignment.  The first line of the article makes clear that this was going to be unhappy reading.

“Medical students at the University of Sydney invented patients, falsified records and even "interviewed" dead patients in a serious academic scandal which has shocked the respected medical school.”

Academic dishonesty does occur. No University and within them, no faculty can be totally immune to this.  However, in medicine, the thought of anybody cheating would not cross the minds of many.  There will in fact be some element of denial as we think of ourselves as having ethical and moral behavior as part of our DNA and we also believe that none of us should lack the intellectual capacity to pass an examinable task.   

Do we really have exemplary moral and ethical behavior that makes us stand out above the general population?  I think that see enough to the contrary in the press on an almost daily basis. It makes clear that we in the medical profession have the same human failings as any other group.  I do not need to bore you with the stories of doctors rorting the public purse, goading patients into thinking that they need cosmetic surgery, gross negligence in medical practice and more recently, the uncovering of rampant sexism and bullying culture in specialty training.  On the other hand, there are equally as many, if not more, stories of amazing things that the medical profession is doing for public health and individual patient care. The clear message is that in spite of the amazing things we can do,  we as medical students have the capability for academic dishonesty as anybody else.

However, why should we have a need for academic dishonesty as a medical student?  I am trying to get my head around this.

The pass rates for various subjects or assignments in the medical course are very high but this should not be surprising because it is regularly those who have been high academic achievers who gain entry into medical schools.  It is generally thought that if you can get into a medical course, then you should be more than capable of passing the course.  It has always been my view that if somebody ever failed a subject or assignment in the medical course, that it was a reflection of total lack of application or there being significant external distractions that have impacted upon attention to their studies, rather than anything to do with intellectual ability.  We are talking about less than 10% who might fail on their first attempt and most of these students will get through on a second attempt. Once again, there should be little need and therefore incentive for a medical student to cheat on their examinable tasks.

The SMH article asserts that there is “proven wide spread academic dishonesty.”  There is no citation or proof provided that this is the case. What follows in the next sentence is that the University has acknowledged that there have been three students who graduated last year who are under investigation for academic misconduct. The article also states “It is understood at least 70 students from a class of more than 200 were involved.”  There is no attribution to any organization or individual, even anonymously.  If we consider the class size as being say 350 students, this would suggest that we have 20% of our students who are dishonest and this simply does not fit in with my experience.

I have personally assisted students in identifying or advising them of the suitability of certain patients who would potentially volunteer to assist with their IPM assignment.  As a result of significant hands on teaching of medical students at my clinical school, I do get to know many of them quite well and to suggest that 20% of them were dishonest simply does not stack up.  In the absence of attributing a source whether anonymous or not, makes me suspicious about the validity of these claims.  I have asked the article journalist for a response through twitter and hopefully she will respond to clarify these points.

I am absolutely sure that academic dishonesty does occur in my own faculty and in my own university but I am to be convinced that it is widespread or highly prevalent.  I have personally found the vast majority of medical students that I have interacted with to be kind, personable, empathetic and committed to one day doing the best for their patients. 

If academic dishonesty is occurring whilst as a medical student, I do have concerns. If past behavior is to be the best predictor of future behavior, we have every reason to be concerned if these individuals were to be placed in a position where we count on their honesty.  Did they make up the blood test result that I asked them about because they forgot to look it up?  Did they tell me that the pedal pulses where present even though they didn’t check them and took a gamble that they probably would be?  And one day when a patient asks them as a specialist if they had spoken to the second opinion doctor as they had promised but had not, the line has already been crossed. 

When I think of senior doctors who behaviour rattles me, I think back to their behaviour either as medical students or junior doctors and in highsight I realise that nothing has really changed. This is not to say that people are not capable of change but it worries me.

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Henry Woo is a medical graduate of the University of Sydney.  He is a fractional salaried Associate Professor of Surgery of the Sydney Medical School of the University of Sydney.


  1. Dear Dr Woo:

    As a graduate of a similarly large medical school in the USA (class size ~250) which recently had an analogous cheating scandal, I think the fault lies first with the students themselves, and then with the faculty who create an environment in which such behavior thrives. The situation in my case was with pathology quizzes, which amounted to less than 2% of the overall grades that year. Yet 20-40 students had formed a cheating ring to share answers. I don't know the exact number, because as soon as the administration learned of the scope of the problem, they simply failed everyone who had been caught rather than expel them and risk a public embarrassment.

    The faculty were shocked that students who worked hard to gain admission to medical school risked throwing away their careers for 2% of a grade. It was less of a surprise to the student body. Our school had a reputation for being competitive and selected applicants primarily on the basis of academic achievement. Once we were admitted, the only way to describe the next two years of medical education was total abandonment by the faculty. Students were expected to pull themselves up by their bootstraps which is not inherently a bad teaching model, but it selected for the most cutthroat individuals who engaged in dirty tactics to be at the top of the class. For example, on the first big exam of the year, someone sent out the "last year's test" which they had supposedly found online, complete with full answers and explanations. It turned out to be completely fabricated, with incorrect answers.

    The survivalist attitude even extended to personal interactions. The same high achievers were masters of the kiss-up kick-down mentality. They could put on a show of empathy long enough to allay any suspicion, and then turn around and be shockingly cruel to their fellow students and utterly transparent in their goals. Again, this was who was selected for: anyone who could fake decency during the 15 minute admissions interview was rubber stamped, as long as they had stellar test scores.

    Thankfully, during the clinical years some of these students were exposed: either for blatant lies about patients, racist or sexual harassment, or for arrogance towards their fellow students. Nevertheless, I am terrified that a signficant number of these students are medical graduates and will be practicing medicine.

    There may be no practical way to screen out such personalities. I have a couple of suggestions that may be far fetched:

    1) during the admissions process, there ought to be a rubric to flag potential "gunners" - do they have stellar grades and no extracurricular activities that required them to work with other people? Were there extenuating circumstances that prevented them from doing so? How do they respond to hypothetical scenarios where their ethical center may be tested? Above all, do they pass the gestalt test of "is this a human being I am talking to?"

    All of that will take more than 15 minutes so I don't see it being implemented in any admissions committee in the near future.

    2) During medical school itself, the faculty should strive to create an environment where honesty is rewarded rather than having the correct answer 100% of the time. The fear of failure and of losing face is a powerful corrupter. It's why students lie on the wards and cheat on tests. This is primarily by the example of seniors and residents. When their dishonesty is overlooked, bad behavior is encouraged in the junior students.

  2. Thank you anon for your thoughtful post. The problem could well be a combination of the system and the individuals who succumb to it's corrupting influences. There are of course those who have never had a moral compass.

  3. OK this is anecdote, not evidence, but it may shed some light on how this might be happening. Last year I fell into conversation with a recent medical graduate of a Sydney university. She told me how competitive it had been to get into medical school, and in her class year there was a group known as the '100 Club' who boasted of getting straight A grades in everything. She described them as a group whose families and peers had pressured them from an early age to achieve. They had 'helicopter parents' and had attended coaching classes from an early age. They had been pushed into medicine as it was the most prestigious career rather than having a vocation for it. These students had been taught every trick in the book to get straight A grades - they didn't leave anything to chance. They rehearsed essays and interviews, paid for tutors to help them with every assignment and learnt how to tick every box. The medical graduate I spoke to was scathing of them - saying they had no genuine outside interests and limited social skills, unless it was to look good on an application form. In other words, their whole lives were focused on getting on top. For them, faking an assessment would be no big deal and would be seen as just another tactic to make the grade. This was just a small group, but nevertheless a very real one to her. She said they had all graduated top of the class and were using the same techniques to get into their favoured - and highly selective - speciaties.

  4. Unfortunately the future will be very bright for such individuals. We in medicine have always cultivated the good old boys, the power-hungry, and the money-obsessed as leaders and examples. It is no surprise that the field attracts those wishing to emulate them and we are simply reaping what we have sown. Only when the public prestige attached to being a doctor diminishes, and the paycheck correspondingly, will things change. I also doubt that academic dishonesty of this scale is anything new in medical schools. At least these kids aren't sleeping with the professors for answers or deliberately sabotaging each others careers that we know of.

  5. Great comments. The problem is very real and certainly needs to be addressed. I am prepared to accept that I have probably been in some degree of denial about the prevalence of the problem.

    Medical students and recent graduates from the University of Sydney medical course have been very quiet on the matter. To me it suggests that they know that academic dishonesty has been occurring and when that's the case, I can understand a reluctance to make comment.

  6. Raymond Yeow, JMO1June 8, 2015 at 10:01 PM

    Dr Henry, thank you for the article; as a graduate of the SMP in 2014, and having done the IPM assessment; I can see how "70 students" may have come about; the IPM requires we meet the pt 6 or 7 times over a 16 mths period - spaced approx. 2 mths apart. A "misdemeanour" would be considered to have occurred if a student did not do the 2 monthly meeting --> but said they had met; or if the meeting was late say 3 1/2 months and the student said that the meeting was within the 2 month mark. The opposite end of the spectrum would be making up a "virtual" patient and forging patient signatures.

    Of the 60 students in my clinical school, I would find it difficult to believe that 20% or 12 of them (or any of them) would have made up a "virtual" patient . However, would some meetings have been missed ie 60 students @ 6 meetings = 360 meetings at least ? ......possible ....and I am not sure how each individual student would have dealt with a missed meeting.

    I am also aware that the PopMed theme was a somewhat disliked part (or alternatively not a favourite part ) of the course by the students .
    If you would like to discuss more, my pager can be looked up in the SLHD directory

  7. Thank you Raymond. I was finding it difficult to come to terms with the idea that as many as 20% could have been involved with academic dishonesty at my alma mater. Since I wrote this blog piece, I have been contacted by a lot of people who have indicated that it is well known to be happening. It made me feel quite naive in my failure to recognise that it was quite a prevalent issue. As I normally do when seeking answers, I went to Pubmed to look up research done on academic dishonesty in medical schools and I was shocked to see that it is well established this is occuring when the circumstances allow. In one study, it was happening in over 90% students and with a culture that it was okay.

    I received comments about the PopMed task - "The task was regarded with contempt universally. It was a PhD for someone who wanted to use it for their own academic career." and " I always did IPM properly but thought it was empty tickboxes for the uni, and if I found out my Dr had fudged theirs I wouldn't care". This is worrying and makes you feel as though the university had set fertile ground for academic dishonesty for the PopMed task.

    I was also critical about the lack of comment by any current medical students and recent graduates from the Sydney Medical School. I was shocked to receive a message that the current students were advised by the Sydney University Medical Society (student body) to make no comment about the matter. In my opinion, this is potentially more damaging as the silence implies that academic dishonesty accepted to be happening and with high prevalence. It also implies some sort of cover up. I personally think that this stategy has backfired.

  8. Hi Doctor Woo,

    I am a current student in the Sydney Medical Program and would like to make a few quick comments:

    1. Excellent article - I certainly hope that the journalist who wrote the original piece does reply to your enquiry.
    2. My understanding is that there was no serious academic dishonesty found but, like Raymond mentioned, a lot of "fudging" of data - eg changing meeting dates to fit within the framework that is required by the assignment. I think that this was normalised because students realised that requiring meetings at certain intervals is not only arbitrary, but also unrealistic (especially when some students met their patients on rural attachments and would have to travel to distant places such as Dubbo and Broken Hill to meet them again after the conclusion of those attachments) and entirely unrelated to patient care.
    3. Re student silence on the matter: this wasn't damage control, but rather self preservation. We have been advised that speaking to the media about the degree is in violation of our expected code of conduct. As much as students would like to clarify their view on what has happened (which the vast majority of us think was grossly distorted by the media coverage) we are scared that doing this will invite retaliation from the faculty. This is also why I'm posting my comment anonymously.

    Thanks again for your comment on the matter.

  9. Hi Dr. Woo. I am also in the class who was recently affected by the "cheating scandal" and I agree with the anonymous commenter above. There was so much fear, bullying and threatening correspondence between the university and the students over this matter that frankly, no one feels safe to comment- even students like myself who were found to be completely "innocent of all fraudulent activity". Even my letter confirming my innocence made me feel guilty....

    I completely understand your viewpoint about the ability to trust doctors who were dishonest as medical students. Initially I felt the same way about those students I had heard about who had made up virtual patients. But I can reassure you that dishonesty in this project DOES NOT equal a dishonest person in general. Maybe that sounds hypocritical, but it's the truth. I personally know of one student who made up a virtual patient (I was shocked when I found out) and many more who made up a meeting with their patient. None of them are gunners, willing to do anything to get a mark, nor dishonest people. They are just students who ran into difficulties meeting criteria, or who completed the allotted task in less meetings than the faculty felt would be necessary. Rather than intrude on their patient for a final seemingly unnecessary meeting, they split one meeting into two journal entries, extrapolated from previous meetings, or made up coffee meetings. I know for a fact that despite this lapse in judgement that they are all 100% genuine and honest in person and on the wards. I am confident that, at least for the individuals I know of, this will not make them worse doctors and, if anything, has scared them into being even more diligent in their medical tasks.

    While I agree that blaming the project doesn't make the dishonesty any better, I do think the faculty should take some responsibility for the situation. This project has been around for two years now and despite receiving a lot of negative feedback from the pioneer year, little was done to change the project for our year. Even now, with the "cheating scandal", the faculty is repeating the project this year. Perhaps some of the blame should lie in the project? Again, this does not excuse academic dishonesty, but certainly the focus should be on less finger pointing and more efforts to improve academic projects for future students. I personally can see the merit in a project like this one and think it is worthwhile, but not in its current format. I have to admit that if I didn't have a patient I knew in a social setting, I'm sure I would have struggled to complete part of this assignment and may even have thought about falsifying a meeting. Yet I have never once lied on the wards to a supervisor. Does this make me a terrible candidate to be a doctor? I wouldn't think so. I think it is a little too much of a generalization to say that all who cheat on a project are generally dishonest.

  10. Thank you to both of you who made the last couple of comments. It certainly helps provide some understanding why there has been a reluctance of students to make comment and give their side of the story.

    Whilst I am sympathetic to the fact that there appears to be serious issues with the PopMed task, one cannot have some concern that there has been the development of a culture where any manipulation of data can as an exception be seen as an okay thing to do.

    As a former President of the Sydney University Medical Society (MedSoc), I am particularly disappointed to hear comments that the student body had made a gag order recommendation - it would have been better to have said nothing to its members rather than to have made any such recommendation. We need to hear what the students have to say about it, even if in an anonymous capacity as above. Transparency will go a long way to help claw back what has been a massive hit to our reputation.

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  13. Just chanced upon it somehow and thought it was an interesting read. Well, not just in medicine, but in many other reputed universities that only admit very high caliber students, some level of academic dishonesty does prevail, and can only be curtailed with necessary checks and balances. In absence of those, natural tendency prevails for finding a solution that requires a least amount of effort.