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 2

How far should medical students go to acquire the accolades that they think will assure them a residency slot in a competitive specialty? I approach this question from two different but related perspectives: that of a program director in orthopaedics and that of a surgeon interested in ethics and professionalism.

There is nothing inherently wrong with Adam’s wish to pursue a career in orthopaedic surgery and join his father’s practice. Students commonly follow a parent or mentor into the medical field and may have an advantage when they do so—first-hand knowledge of the pros and cons of a given specialty and its associated lifestyle. Although this scenario implies that Adam is pursuing orthopaedics primarily to please his father and join a financially lucrative practice, those motives are not certain; nor are they unethical—but they are probably not going to guarantee Adam a satisfying career. Orthopaedic surgery can be highly rewarding but it’s hard work, both during and after residency training, and one must have a real interest and dedication to be happy and successful. There are many paths to financial success that are less demanding than orthopaedic surgery, and (fortunately) most people come to that realization before entering a training program.

As a program director, I would be unhappy to hear about Adam’s conduct on the service. Orthopaedic surgeons place great value on teamwork and the ability to enhance the function of a team, so Adam’s behavior would be seen for what it is: an attempt to make Emmett look bad. Residents in particular can quickly identify medical students who engage in this kind of behavior [1, 2]. Adam’s argument that this sort of competition benefits patients doesn’t justify his actions. Rather than rounding on Emmett’s patients in hopes of showing him up on rounds, Adam should spend his efforts finding ways to help the entire team take better care of the patients. The team’s function is to provide excellent care for patients through attention to detail, compassion, and communication. The team must also work efficiently and accurately. Students who can improve the team’s performance are valued; those who give the impression that their purpose is to show themselves in the best light at another student’s expense are not.

There is nothing wrong with competition per se. The American Academy of Orthopaedic Surgeons (AAOS) Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery states that “competition between and among surgeons and other health care practitioners is ethical and acceptable” [3]. At the same time, choosing a career in orthopaedic surgery solely for financial gain violates our standards of professionalism, which emphasize that “the orthopaedic profession exists for the primary purpose of caring for the patient” [3]. A surgeon must be able to make decisions in the best interest of the patient regardless of potential financial gain.

Orthopaedic residency is highly competitive, and those who thrive on competition are often successful professionally. Competition may contribute to a surgeon’s motivation to maintain clinical productivity, stay current with continuing medical education, and excel in a given area of interest. Nevertheless, the Guide to Professionalism must direct an individual’s conduct, keeping patient well-being paramount in all professional actions. The same principles apply to medical students and residents. Competitiveness becomes harmful when it drives a trainee to show himself in a favorable light at the expense of other team members. Striving to deliver the most conscientious care you can, be as well-prepared for cases as possible, and help teammates perform their duties are all productive means for competing for favorable evaluations while adhering to aspirational ethical standards. This is what program directors want to see in a prospective resident, because those who demonstrate these values will generally be strong residents and successful orthopaedic surgeons.