AMA Journal of Ethics^®

Case

Adam and Emmett had just finished their third-year clerkships and were doing their first elective. Both had chosen orthopaedic surgery, hoping eventually to be selected for a competitive orthopaedic-surgery residency. Adam’s heart had been set on becoming an orthopaedic surgeon for quite some time. He had grown up with an orthopaedic surgeon as a father, and he remembered a conversation with his dad right before he started medical school that, in retrospect, had been a real turning point in his life. His dad had said he would be proud to have Adam join his practice. It was the first time his father had said anything like that. They had talked about it off and on in the years since then, and Adam had grown increasingly interested in the idea of doing orthopaedics and joining his dad’s practice, knowing it would mean a comfortable life.

Adam received good clinical grades, scored above average on USMLE Step 1, and continued to develop an interest in orthopaedic surgery. The pressure to do well on the orthopaedic rotation, get a good letter of recommendation, and rank among other well-qualified applicants prompted Adam to become increasingly competitive.

He began arriving before Emmett in order to pre-round on both his and Emmett’s patients, hoping that he would be able to answer a vital question if Emmett faltered. Adam was initially disturbed by his increasing willingness to be so competitive, especially at the expense of another student. But, over time, he grew accustomed to it, driven by the prospect of joining his father’s successful practice. He reasoned that surgery was difficult, and the competitive culture actually benefited patients; it meant more people were being attentive to the details of each case. He wondered if he was upsetting Emmett, but told himself that Emmett was free to be just as competitive and that, in the end, the harder working, more deserving student would be selected to an orthopaedic residency spot and make a better surgeon.

Commentary 1

The task of securing an orthopaedic-surgery residency or any competitive residency position can be difficult and nerve wracking. With increasing enrollment into medical schools and relatively few orthopaedic-surgery residency training positions, prospective students must find ways to stand out from the crowd. This is not a new concept for students; it is not unlike the process of being accepted into medical school. Candidates must have excellent medical school grades and USMLE Step 1 scores and show exceptional interest in their prospective fields. Research in orthopaedics, including publications, is expected. Extracurricular involvement, volunteer experiences, and leadership experiences are required. High performance on clinical rotations is crucial for acquiring good recommendation letters and ultimately interviews for competitive residency positions. A deficiency in any of these areas may result in a failure to match into orthopaedics.

Residency programs must choose candidates wisely to balance surgical training with effective patient care. When a residency program admissions committee identifies a profile of its ideal candidate, that person is most likely intelligent, teachable, enthusiastic, and professional. Good ways to measure these attributes are by performance on clinical rotations and by letters of recommendation, which give programs an idea of how a candidate will perform as a resident.

In this case, Adam’s motivation to become an orthopaedic surgeon is clear. He looks forward to the prospect of joining his father’s practice and has excelled in his first year of clinical rotations. It seems that he is on track to achieve his goal by receiving good grades, scoring well on USMLE Step 1, and doing his best on his orthopaedic clerkship.

Driven by his nervousness about his orthopaedic clerkship performance and his desire to join his dad’s practice, Adam finds himself increasingly competitive, turning to “one-upping” Emmett and arriving early to pre-round on all the patients. Adam has justified these actions by incorrectly assuming that they are what make a good surgeon and that they will benefit patient care [1]. He further rationalizes that his tactics are acceptable because Emmett could do the same if he chose to work as hard.

Adam has fallen prey to an all-too-common misconception of surgical training and medical education. Perhaps this should not be surprising: who hasn’t heard a story about a narcissistic surgeon? The idea that competition has to be cutthroat with a “take no prisoners” attitude, however, is foolish and counterproductive to the team approach of medical care. Current medical care is complex, requiring specialized health professionals and the need for these professionals to collaborate and communicate effectively [1-3]. This may be particularly evident in surgical-training programs, where students and physicians with different levels of knowledge and experience interact to provide patient care both on the floors and in the operating room. Self-serving behavior like Adam’s does not benefit patient care, and could anger Emmett, which would lead to a breakdown in team communication.

It is foolish for Adam to think that his poor behavior will go unnoticed. The residents he is working with have overcome similar challenges in their surgical training and may not appreciate Adam’s antics. News of his actions may even find its way to attending surgeons who will be wary of introducing a potentially destructive element into their residency programs. Adam’s behavior will almost undoubtedly backfire. Interestingly, Adam himself was initially disturbed by his actions. This should be a good guide that his behavior misses the mark.

If Adam is lucky, the residents he works with will offer constructive feedback about his behavior. I personally would tell Adam that his willingness to work is excellent, but there are better ways to stand out that are not at Emmett’s expense. I would direct Adam to focus on his own assigned patients and all aspects of their care including the diagnosis and classification of injury, different types of surgical treatments, postoperative care, and physical-therapy needs.

Adam’s behavior will also affect Emmett. There are many ways that Emmett could react, but his best course of action is to discuss the situation early on with Adam. It is reasonable to think that with a cooperative effort both can excel in the rotation.

Medical students strive to stand out from an already exceptional crowd. Despite Adam’s example, this can be done while maintaining integrity and professionalism. A competitive environment can motivate one to exceed expectations. On the other hand, it can cause some students to resort to underhanded tactics in an effort to differentiate themselves from their competitors. Hard work and an interest in the field are a good start, but they are not enough. Becoming a well-rounded candidate is also necessary, and this requires developing communication and leadership skills. A hypercompetitive attitude will undermine these aims. Adam and other medical students applying for competitive residencies should work to stand out individually while maintaining a team-player attitude.