Making the Rounds The Ethical Development of Medical Students in the Context of Clinical Rotations

Often in the hospital setting I feel I intrude into people's lives, take what I want, and move on. Does the experience of serving as a clinical clerk on the hospital wards change the ethical views and moral values that students bring to medical school? If so, what aspects of this experience and its environs most affect students' ethical development? What are the fundamental elements of the ethical dilemmas that students encounter, and what do these dilemmas reveal about the medical training process and the basic 'human condition' of young clinical clerks and house officers?[1] These questions, based upon earlier studies of medical students and our experiences leading ethics discussions among third-year students, frame the subject of this essay: the actual ethical predicaments that clinical clerks struggle with. In a previous paper we provided a taxonomy of student ethical dilemmas, emphasizing that the predicaments students confront differ from those that house-staff and attending physicians face.[2] Here, we want to explore these dilemmas in greater depth by examining the social context in which medical students encounter ethical quandaries, with particular focus on the hierarchy of authority and power that exists in hospital medicine. This hierarchical social structure configures the ethical difficulties that medical students encounter--dilemmas that display some of the deep cultural paradoxes and ambivalence manifest in current hospital practice. Students' interactions with these dilemmas, in all their social and cultural dimensions, shape their personal ethical development. Our intention in this essay is to illustrate, ethnographically, the importance of these dilemmas for students' moral conceptions of medicine, and to make recommendations that we hope will enable students to maintain and nurture their ethical self-identity. First Steps: Medical Student Ethical Dilemmas I was on my first rotation of internal medicine as a clinical clerk. One evening, Mrs. S arrived on the floor. My senior resident, having already interviewed and examined Mrs. S, told me that this ninety-year-old who presented with a swollen leg would be a good patient for me to follow. Knowing that this rotation required me to perform several thorough histories and physical examinations, I was eager to get started, and I went to her room. It was nine o'clock. Largely because of Mrs. S's hearing impairment, it took me two hours to complete her medical history. Before I had begun the physical exam, my resident knocked on the door to tell me that Mrs. S. needed blood cultures and labs sent. Since the intern was busy working up another admission, she told me that I should get them (even though it would be only the second time I had drawn blood). Mrs. S.'s patience began to wear thin as I fumbled through several phlebotomy attempts. It was past midnight. She was tired and growing uncomfortable. I began to wonder: if I resume my examination, am I serving her needs or my own? ... Probably every seasoned clinical clerk, through either firsthand experience or secondhand anecdote, could recognize the outlines of this case--its protagonist combining an earnest desire to help and to learn, but beset by conflicting feelings of self-doubt and frustration. During the 1991-92 academic year, as fourth-year student preceptors of an ethics minicourse that all students took during their first clinical rotation in internal medicine, we listened to dozens of similar accounts as we explored with 150 third-year medical students the nature of the ethical world in which they worked. …