The troubling inconsistencies within the medical educator role

Abstract

At the time, I did not know why, but I was dreading this meeting. I was waiting for a first year medical student who had been five points below the minimum performance level (MPL) on the Course 1 summative examination (her first examination in medical school), had passed the summative examinations for Courses 2 and 3, but then scored 1.3% below MPL on the repeat Course 1 examination seven months later. I was meeting with her to discuss the procedure whereby I would present her case to the Student Academic Review Committee with the recommendation to repeat the first year. This procedure had been in place for many years, was clearly outlined in the Student Handbook, and met the procedural requirements for accreditation by the Liaison Committee for Medical Education (LCME). So what was my problem? Was I troubled by the fact that when interacting with medical students the ranking for ethical principles is quite different from how I relate to my patients? In the upcoming meeting, we were not planning to explore her perceptions of her learning needs and then tailor a remediation program to these. We had no intention of weighing the benefits of our recommendations against the financial implication of repeating her first year (and possibly working one year less postgraduation), or the trauma of having to form a new peer group and explain why to her former and future peer groups. And we were not about to discuss the fact that by forcing her to repeat her first year there would be one fewer new applicant to medical school this year and one fewer physician graduating two years from now. Instead, in our education practice, we follow the all-powerful principle of institutional policy, and my role during this meeting would be to explain this to her. Or perhaps I feared that she would ask for data on the predictive validity of our evaluation tools. What is the risk of her being an incompetent physician given her inability to achieve the MPL on Course 1? And by how much is this risk reduced if she repeats her first year? In our clinical practice, we teach students to use screening tests only if they can reliably predict meaningful outcomes, and to recommend treatment that has been shown to improve these outcomes. Our education practice requires us to have screening tests along with procedures for dealing with students who fail these tests. We are not actually obligated to demonstrate predictive validity of these tests or efficacy of our interventions (Woloschuk et al. 2010). Kohlberg’s (1973) theory of moral development recognizes three distinct levels of reasoning: pre-conventional, conventional, and post-conventional. In the pre-conventional level (which is typical of young children), decision makers are egocentric and are concerned with maximizing personal gain, e.g., in receiving rewards and avoiding punishment. The focus at the conventional level, which is achieved by most adults, is on conformity to social norms (or MPLs) and maintaining law and order. Adults who progress to the post-conventional level are capable of abstract moral reasoning and judge actions according to their own moral principles – even if these are at odds with social norms or regulations. In Kohlberg’s view, we progress invariably through these stages and at that any given level or moral reasoning we consistently take the same perspective across different areas of content (Kohlberg 1973). Kohlberg’s theory is still the dominant framework in the area of moral development, but others in this field have