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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Disclosure

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.

Cardiac Surgeons Were Once Untouchable

About 30 years ago, coronary artery bypass graft surgery (CABG) was the mainstay of treating narrowed coronary arteries that supplied blood to the muscle of the heart.  Such surgery was predominantly, if not all, performed in the public hospital system where there were long waiting lists.  Demand outstripped supply of such service and cardiologists were at the mercy of cardiothoracic surgeons who could determine which of their patients they would accept for treatment and the priority afforded to them.  The CABG was a genuinely life saving type of surgery and the high success of this surgery by highly trained surgeons provided them with unparalleled status in the hospital pecking order.  The cardiac surgeons received the adulation of the press and public for the life saving work that they were performing and sure enough, they came to truly believe that they were the heroes of the medical profession.

The behavior of cardiac surgeons was one of self-entitlement and demand for unquestioned respect and admiration.  Whilst capable of great empathy and care for their patients, they treated members of their surgical team and own profession with disdain and at times unbelievable cruelty. As providers of essential services that were in short supply and high demand, hospital administrators would bow to unreasonable demands. They were effectively untouchables.

Whilst there are too many stories to mention, here a couple that I recall as vividly as if it happened yesterday. 

When I was a junior doctor, I had softly remarked that my nose was itchy under the theatre mask. This was overheard by “sir” who then came up to me and squeezed my nose and twisted and said “this will fix it” and went off laughing.  The pain was excruciating and I quietly slipped away outside the operating room pretending that it did not hurt at all. My nose was bleeding.  Once cleaned up, I returned to the operating room and pretended that nothing had happened.  I did not dare challenge him for this assault and I also knew that nobody in the room would dare to support me for all of us were afraid of him. 

My six months as a surgical registrar to “sir” was a tough gig psychologically, The work itself and at times long hours was never an issue but the constant barrage of abuse was taxing.  I was so ashamed of admitting that it was getting to me that I recall not even discussing it with my girlfriend of the time (who was also a junior doctor) or any friends as I felt that I could not afford to demonstrate to anybody any sign of weakness or potential inadequacy to make it through the rigors of surgical training. “Sir” loved an audience and we would usually have up to twenty people in the operating theatre to observe such as medical students and physiotherapy students.  He just adored the physiotherapy students, particularly the attractive female ones who appeared to get special attention and this was returned with blushing adulation.  Not uncommonly, I would start closing up the wound and he would go out to make a phone call. He would then return and yell to the entire room “Henry, you’re meant to be getting better, not worse” and would then storm out of the theatre.  The operating room would then be so quiet that you could hear a pin drop above the noise of the anaesthetic monitoring devices. I could go on and on, but I made it through.  I survived.

In later years I had transferred training programs and went from being a general surgical registrar to a urology registrar.  At a different hospital, I entered a service lift and the only other occupant was a cardiac surgeon, a different “sir”.  He did not acknowledge me in any way but what did I care.  The next floor, a wardsman entered the lift and tripped over the lip of the elevator floor and bumped into “sir”.  Yes, he committed the greatest possible crime and touched “sir”.  Over the next couple of floors, “sir” proceeded to abuse him “how dare you blah blah blah …..” and refusing to listen to his repeated attempts to apologise.  The wardman was petrified that the surgeon would lodge a complaint and that it would lead to his dismissal.  I was so shocked that I stared in silence and whilst he had little ability to impact on my future career, I was still too frozen in fear to say anything.  Immediately after the event, I felt enormous guilt for having said nothing. For me it will always be one of those moments that you remember where something could have and should have been said.

These stories are pretty tame compared to others I have heard. The fortunes have changed significantly for cardiac surgeons.  Coronary stents are now used where surgery was once necessary. Cardiologists control the flow of work to cardiac surgeons and can make or break the success of their practices.  I have personally seen where a cardiac surgeon at a hospital I worked at was completely starved of work to the extent that he had to take a salaried position interstate.  There was never an issue with his clinical judgment and technical skills but with a totally obnoxious personality from the cardiac surgeon old school, his private practice disappeared in favour of other surgeons who were prepared to be more personable.  Cardiac surgeons can no longer be seen to be self entitled poisonous individuals.  Everybody knows that cardiologists are the masters of cardiac surgeons and what huge fall it has been from the top of the ivory tower.

Having said all that is above, I have great respect for my cardiac surgery colleagues. Their professionalism and care for my own family members who have needed their skills will always be appreciated.  I really believe I have seen the worst and now best that these surgeons can offer.  

At least in this surgical specialty of cardiac surgery, technology and medical advances have had a positive affect on surgeon behavior. 

Bullying Culture in Surgery - Has Nothing Changed?

The airing of the Four Corners report on an entrenched culture of bullying of surgical trainees and medical students has for the very first time pushed this matter into the public spotlight.  The obvious reason for the suppression of this ugly behavior is the enormous power imbalance that exists between perpetrators and victims.  Medical students, and particularly surgical trainees, are unwilling to come forward as their career progression is totally at the mercy of those who have significant influence over the results of their progress reports.

I hear the argument from a number of my colleagues who say that everybody is getting too soft and that they dread the ability of these ‘mollycoddled children’ to handle the stress of dealing with catastrophic bleeding at 3 am in the morning. I totally reject this assertion as justification that an intimidating bullying culture has a role to play.  I am not aware of any evidence that a non-confrontational approach to training will impacts upon the ability to perform following the completion of training.  When we look at the commercial airline industry, it is the meticulous training that prepares pilots for a variety of catastrophic events.  Being yelled at, publicly humiliated and often being left wondering what it was that was done wrong (because one could not dare ask what it was that was done wrong as one should know) is not training. 

It is bullying and harassment and nothing more.

I was on the receiving end of bullying during my training, particular at the hands of a cardiac surgeon, well before I started training in urological surgery.  At that time I felt that he had total and absolute control over my career.  However, it was far more often that I observed my junior colleagues being on the receiving end abuse and harassement. What worries me is that many of my colleagues who were bullied and harassed as junior doctors, do not reflect back as this having been the case.  This is how the cycle of bullying continues. Their interpretation of bullying has been reset by their experience to become a norm of surgical training.  They too go on to repeat the behavior experienced during their formative years as surgeons.  The words of Dr Vyom Sharma are chilling but demonstrate great clarity in the problems we face: –

"In one moment I could just see how this all happens. Someone bullied him, he bullied someone else, and now it's my turn."

The stories on Four Corners make me worry and wonder if it really could be a case of where “Nothing has changed”.

Maybe I should provide some context of how things were different when I was training.  I was absolutely everything that was atypical and confrontational to the surgical establishment when I wished to undertake surgery as a career in the late 1980's. 

I was Asian, went to a public high school and at that time, hated rugby. 

I was definitely not “one of the boys”. Tearoom discussions were often lonely as I had no ability or real interest to discuss the results of the last weekends’ private school rugby game or who should play fly half for the upcoming Bledisloe Cup.  Apart from clinical matters, I had very little in common with my surgical seniors.  My colleagues who fitted the perfect surgical role model would regularly get the pat on the back for being a ‘good bloke’ and were rewarded with more opportunities to try their hand at surgery. The diversity of surgical trainees and subsequently trained surgeons has changed enormous since then due to surgical training programs being taken out of the hands of individual hospitals and therefore the hands of a very few powerful individuals.  Centralised selection for surgical training was a very positive step forward although for general surgery it was introduced after my time.  I remember having little support base as none of the surgeons were really my ‘mates’ but I was fortunate to have sufficient numbers of surgeons who saw that I had talent and were prepared to put their reputations on the line to help me achieve my career aim.  I always remember this as a reminder that there was also a lot of good in many of the surgeons who mentored me as a junior doctor and it was not all bad.


*****


(Note for those outside of Sydney - back in the 1980's Rubgy Union was a game that was almost exclusively played in elite private schools. Public schools and non-elite private schools tended to play Rugby League.  Back then, the vast vast majority of surgeons had been educated in the private school system apart from a handful from exclusive selective public schools)

Robert H. Farnsworth - my hero in urology

At the Gala Dinner of the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting on 13 April 2015, a special man was the recipient of the Society Medal (USANZ Medal). 

Robert Farnsworth's achievements are well known within my profession.  

The next few tweets sum up my thoughts

I was in my final year of urology training when I worked for Bob. Just some of the things that I recalled from my time with him included

1. treating everybody with equal kindness and respect, whether a janitor or internationally acclaimed professor
2. never ever making me feel bad when there was something that I could have done better
3. always having time for me, even for what in hindsight were trivial matters (even if this meant him going home later than planned)

When I returned from additional training abroad, I entered independent practice and there were a number of occasions that I would call him for clinical advice. Even though I was now his competitor, he continued to be so willing to share his wisdom.

It was a proud moment for all of us who have had the privelege of training under him to see him awarded the USANZ medal.  He's the closest you get to a Mr Holland (as per the movie Mr Holland's Opus) that would be possible in the Sydney urology scence. 

If something happens to me, will I have done enough to enable a colleague to continue the care of my patient with newly diagnosed prostate cancer?

As an academic surgeon, I probably get to see more second opinion cases than for most in my field. My university association and digital footprint probably tends to attract these cases although I make absolutely no effort or attempt to attract these consultations. Of course there are some that arise as a result of contact with patients I have previously treated. One thing for sure is that I do not send letters out to GPs asking them to consider asking their prostate cancer patients to switch specialists. Likewise, I do not have second opinion forms on my website goading readers to switch specialists.  Maybe I am totally deluded into thinking that I see more second opinion cases and that my load of such is exactly the same as everybody else. 

Many of these consultations are for those recently diagnosed with prostate cancer. Recently, I saw a man who had undergone transperineal prostate biopsies and had been diagnosed with prostate cancer. Transperineal prostate biopsies are where the sampling needles traverse the skin of the perineum (patch of skin between the anus and the scrotum) rather than going through the rectal wall with so called transrectal ultrasound guided prostate biopsies.  

The samples were labelled A1 through to A8 and B1 through to B8.  There was no anatomical indicator as to where these biopsies were taken from within the prostate. To make an intelligent guess, it might be that A represents apex of the prostate gland and B represents the base of the gland but who knows other than the original surgeon doing the biopsies. There was an additional sample which was called the targeted biopsy.  This would have meant nothing except for the fact that there was an MRI scan of the prostate that had indicated that there was a tumour suspicious lesion towards the centre of the gland (left transition zone to be more precise).  

It was the cancer in the targeted sample that demonstrated that there was cancer that needed treating.  There was also a tiny speck of cancer in one the ‘A' samples but it was low grade and probably clinically insignificant - in other words, one that could be ignored. In this situation, knowing what the A and B samples came from was academic. I knew that the cancer was in the middle of the gland and that this patient would likely do very well with so called nerve sparing radical prostatectomy. 

This case did get me thinking.  All sorts of questions were running through my head. What if there were clinically significant cancer deposits in the A or B sets of biopsies? I would have no idea as to where they were.  The naming of these samples was not standard nomenclature but rather a special code used by the surgeon who took those biopsies. I could always write to him if I need to know to plan surgery and therefore avoid having to put a patient through another biopsy to map the cancer.  What if the surgeon was not willing or obstructive because he was ‘losing’ a patient?  Was this some ploy to make it harder for the patient to switch surgeons? What if something were to ever happen to the surgeon - we are mere mortals and not the demigods that some surgeons think of as themselves.  If another surgeon were to have to take over the care of that patient in the event that the original surgeon became serious ill or were to become deceased, access to this ‘secret code’ of labelled specimens could be an issue. I have no answers to these thoughts but I am clear on what I do in my own practice. 

I always label my prostate biopsy specimens in a way so it is crystal clear as to where they have come from. If something were to ever happen to me, I could feel assured that a colleague would be in a position to take over the care of my patient.  I think that this is a minimum standard of care but there seems to be no appetite to make change.  

Why won’t pathologists push their referring urologists to be more diligent in writing better clinical details or appropriately label the specimens? In Australia, the vast majority of prostate cancer are treated in the private sector. In a competitive pathology environment, no pathology provider would be comfortable about demanding improved clinical documentation and labelling of pathology specimens from referrers in whom they depend on for their work.  How do you think we can drive change?  I certainly have my ideas but I would like to hear yours.

Poaching staff is not the done thing. Or is it?

It takes a lot of effort to train up a surgical assistant, particularly with complex surgery. Surgeons who have been involved in this process will by virtue of human nature and tradition of self entitlement, feel some sense of ownership for the person that they trained and the expectation of some loyalty.  I am not saying that this is a correct way of thinking but it is human nature.  

Over the past week, two of my surgical assistants were approached by a colleague in my specialty who attempted to entice them away with significantly greater remuneration. The initial reflex response was "How dare he?" and “This is totally non-collegiate”.  Both of them had no interest in changing surgeons but had rightly done their own due diligence to learn more about the surgeon making the offer. They had both come to their own conclusions on the basis of feedback that they would prefer not to work elsewhere in spite of the higher remuneration. 

Initially I felt a little irritated but this was very quickly followed by the rationalisation that we have an open business market in Australia and this type of activity is fair game.  Whilst surgery is associated with a special relationship that the defines the patient-doctor relationship, there is a business side to it that is no different to any other business.  For example, Virgin Australia is free to approach key Qantas staff that it may wish to headhunt for a role in its own organisation.  Even though Qantas may have been invested enormously in training a given individual, they have no ownership of that person’s career destiny.  

Whilst the behaviour of headhunting staff is nothing unusual outside the medical profession, we have to learn to adapt to the fact that we are subject to same market forces and expectations as any other business. The old boys club approach to how we do our business does not cut it anymore.  This is no different to how the medical profession must be expected to deal with issues of sexism and harassment like any other profession with the same transparency and commitment. Time to get to down from the ivory tower.  

It Was All My Fault That a Patient Died.

Back in the late 1980’s, I was working as a junior general surgical registrar. In such a role, I was allowed to perform minor surgery, often unsupervised. Back then, general surgeons were commonly performing carpal tunnel release surgery although nowadays, they are performed predominantly by specialist hand surgeons. I operated on a man who had bilateral Carpal Tunnel Syndrome.  The surgery was performed under a local anaesthetic block which means that his arm was made numb and he was able to be awake for the duration of this short case. I operated on one side.  All went well.  About three months earlier, he had been operated on the other side by one of colleagues (who was at the same level of training as myself).

Totally unbeknown to me was the fact that an intern had ordered pre-operative blood tests, an electrocardiogram and chest X-Ray in the week prior to the surgery.  These tests in an otherwise well man with no co-morbidity and having a procedure under a local anaesthetic block is unnecessary. I was to learn that this was the case about 8 or so months after performing the surgery and by this time, I was working rotation at a secondment hospital.
I was one of two carbon copied doctors on a letter that had been written by a cancer surgeon.  The other cc doctor was a respiratory physician.  

The surgeon described the history that had led to the presentation by this patient with symptoms. He wrote “somebody had operated on this patient and not checked his CXR which at that time showed an obvious coin lesion in the lung”.  It was intimated that the patient could have been cured of cancer if diagnosed at that time had the CXR result had been checked at the time.  It was very obvious that he was apportioning blame on me for not checking the result of a test that I had not even known or should have expected to have been performed. It was interesting that the same unnecessary work up had been performed for the patients first carpal tunnel operation a few months earlier.  I could see exactly how this would have happened on the second occasion where an bewildered intern just followed what was done on the  previous occasion.

http://grammar.about.com/od/ab/g/Bad-News-Message.htm

I was devastated to receive this letter.  I did not dare communicate with the surgeon to explain my case as I truly believed at that time, any disagreement with the surgeon would be the end of surgical career. Over the next 18 months, I continued to be copied in on correspondence outlining the patient’s demise in spite of curative attempts and ultimate death.  Every time I received these letters, I would fall into depths of depression for several days but I would always develop a mechanism to cope. When the letters arrived, dread would fill my face before opening the envelope as I always knew what lay within.  I would go to a room by myself and read it again and again and again.  I looked at it as being my problem and could not feel I could raise it with anybody, including my partner at the time or my surgeon mentors.  He had amassed incredible power in surgical politics and was not one to be reckoned with.  I was totally and absolutely petrified of him.

Periodically I would think of this case and it was not until some 15 years after the event that I would seek closure. This matter had ruminated in my head like a festering sore.  This process began went I was invited to a 50th birthday party and at dinner happened to be seated next to the respiratory physician who was involved in the case.  I found myself opening up to him about this story that I had kept locked away for so many years.  It was quite liberating to be able to speak about it for the first time.  It was amazing that he seemed to remember the case.  The physician was less than complimentary about this surgeon's general behaviour over many years that had been characterised by bullying, narcism and arrogance.

I had copies of the letters and selected additional clinical information and certainly more than enough evidence for commencement a bullying claim.  I had already briefed a high profile lawyer who was eager to take the case,  Given the particular high profile of the individual and what she considered to be unjust treatment, she was prepared to commence this case without any cost to me. I reflected and asked her to allow me do one last thing before commencing litigation.

I took the step of writing to the surgeon who at this stage was a national figure. He was  big fish to fry if I were to take the matter further. He wrote a meticulously neat hand written letter to me explaining that he regrettably had no recollection of the matter and wished that I had been able to raise the matter with him at the time. The final paragraph was repeated unreserved apology.

Whether the apology was disingenuous or not, I felt that I had got this matter off my chest and he was now aware of what I had experienced as a result of his actions. The act of opening up about this case and to then communicate my story to the perpetrator was extraordinarily liberating to me and to the extent that I had lost energy to commence litigation that was destined to make the press.  

I destroyed the documents.  The matter was over from my perspective.  The chapter was closed.  I did not think about this story again until the recent media coverage of harassment in the medical workplace.  I have my blog and here is my story. Do you have a story to tell?

Click below for:-

Background to my relationship with the surgeon discussed is covered in the short piece that precedes this post.