Photo by Hush Naidoo Jade Photography on Unsplash
Abstract
This pair of narratives engages with the moral and emotional tensions experienced by a medical student and a faculty physician in the context of a clinical encounter involving an incarcerated patient. The student narrative recounts the discomfort and internal conflict provoked by witnessing behavior she perceived as racially biased and dehumanizing, alongside her uncertainty about how—or whether—to speak up. The companion piece, written by her faculty mentor, reflects on this moment through the lens of the hidden curriculum, arguing that medical education too often neglects to cultivate the moral courage necessary for such moments. Together, these essays illuminate the silent lessons of professional socialization, the limits of formal ethics instruction, and the urgent need to teach advocacy and moral agency as core components of clinical training.
Essay 1 of 2: Confronting the Gap Between Classroom Ideals and the Reality of Clinical Culture: A Medical Student’s Perspective by Isabelle Band
Case
A surgical resident ushers me, a medical student on her first day of third-year clinical clerkships, into the trauma operating room (OR) and whispers, “Inmate from Rikers. Stabbed four times. They need a student to help them retract.” The patient is JA, a 31-year-old man with no past medical history presenting to the emergency department at a public hospital in New York City, after sustaining a penetrating stab wound to the abdomen with omental evisceration. After stabilization, he is rapidly transferred to the OR for exploratory laparotomy.
Three surgeons surround the operating table where the patient is intubated and his abdomen dissected and splayed open from sternum to pelvis. Despite my earnest attempts at suctioning, blood decorates the team’s blue gowns and seeps into their socks and shoes. As the surgeons systematically “run the bowel,” sliding their fingers along every centimeter of JA’s small intestine, the scrub technician leans towards the intern and asks, “What happened here?”
The intern chuckles, “inmate from Rikers. Another stabbing, by another inmate! It’s all in his chart.”
After the bowel injuries are repaired, the attending surgeon removes his gown and gestures to the senior resident, “you got the rest, right?”
She nods. The resident offers me the opportunity to staple closed the incision. It is my first day on the surgery clerkship. The resident models the first few staples, then I take her place and close the remaining length of the wound. The scar is long and crooked, with poorly aligned skin edges in several places. “Good enough,” the resident says. “He won’t care if this looks good.” I leave the OR feeling uncomfortable, but do not mention the experience to anyone.
I had many sessions on professionalism and humanism in medical school, but none prepared me for this moment. What made it so hard for me to speak up?
Commentary
My medical school curriculum dedicated one day per week, during the first and second year, to humanism in medicine. The sessions often focused on the provision of compassionate and equitable care for vulnerable patients, including but not limited to those who are temporarily unhoused, incarcerated, or undocumented. These sessions inspired us. Professors discussed the harms of using stigmatizing language in the electronic medical record and how to write about patients with sensitivity. A panel of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) patients shared experiences of discrimination in healthcare and advised students on providing sensitive and patient-centered care. Small groups of students regularly reflected on systemic racism in the American healthcare system and discussed principles of antiracist medical practice.
As I started my third year and entered the clinical arena for the first time, I anticipated that the real patients I met would be afforded the same painstaking care and thoughtfulness as the hypothetical patients we had discussed in the classroom. Unfortunately, I quickly learned that exalted classroom principles, like confidentiality, devolved precipitously in busy hospitals. I most often witnessed this as seemingly innocuous gossip about patients, which casually floated through hallways and work rooms. Trainees on the trauma service traded shocking patient stories like pieces of bubblegum. During rounds, a resident whispered, “She woke up to her husband standing over her bed ready to stab her with a kitchen knife.” While genuine empathy for patients was usually expressed, I wonder what purpose recounting these narratives served and what harms these casual disclosures produced. Did it allow for the collective reflection on tragic cases? Or did it nourish egos as if to say, this tragedy befell this patient, but I was there to sweep in and save them?
In the classroom, I had learned to avoid talking about patients in hallways and elevators, and to exclude stigmatizing, medically irrelevant descriptors (such as “inmate”) from the electronic medical record and even from discussions with team members. Why were these teachings so readily ignored on the trauma surgery service? Perhaps the team assumed the patient had forfeited confidentiality when JA was admitted to the hospital in an orange jumpsuit, accompanied by a prison guard. Or maybe the team felt a general sense of helplessness against deeply entrenched societal inequities, such as mass incarceration and systemic racism, that had already set JA at such a disadvantage. What additional harm could be borne by gossiping about the only black body in the room, that also happened to be the only one naked and anesthetized? Or by allowing an inexperienced student to fumble with a stapler on a gaping abdominal wound?
Another justification for shirking ethical principles on the floors was that residents, attendings, and other care team members often felt exhausted and overburdened by a broken system. Studies show that high levels of stress and burnout are associated with decreased empathy.[1] Residents worked 24-hour shifts every three days. Given the low volume of nursing staff, surgical residents were expected to wheel patients to the operating room, place IV’s and draw labs. Their exhaustion was compounded by the fact that most of their patients were among the city’s most vulnerable, including incarcerated persons like JA. Pathologies were more often more severe, and patients needed considerable support to ensure they could be safely discharged.
My understanding of this context contributed to my silence in this unsettling situation. If I had spoken up, would the team assume I was questioning their moral judgment or accusing them of providing substandard care and respond defensively? Would I appear idealistic and naive, implying that the team had the time to debrief every case or the capacity to provide culturally sensitive care to every patient on their busy service?
I am not proud to admit it, but I also worried about my rotation grade. I had learned that a key ingredient to a good grade on a clerkship is getting residents to like you, which requires being perceived as helpful but also having situational awareness (i.e., knowing when to be quiet and get out of the way). My experience of feeling silenced was not unique; a 2005 study found that third-year medical students frequently avoided speaking up about ethical conflicts for fear of reprisal.[2] A more recent paper noted that trainees and clinicians most commonly perform professional misdeeds when they are forced to make quick decisions in heightened emotional states, or when they face toxic work environments or hierarchical pressures.[3] This is the clinical reality I had to navigate, yet I was not prepared.
Moral courage is defined as doing the right thing, or not doing the wrong thing, despite the risk of consequences to oneself or other barriers including hierarchy.[4] Speaking up, when discussions about social justice and ethics are discouraged or even dangerous, requires tremendous moral courage. A study about moral courage among residents at Northeastern academic medical centers found that women are less likely than men to act on their moral beliefs, likely due to gender-based differences of empowerment among trainees. Other findings were that interns were less likely to exhibit moral courage versus residents.[5] Subconsciously, I think that being both a woman in a male dominated surgical service and a student at the bottom of the hierarchy, contributed to my silence. Ethicists have suggested that the development of moral courage should be a formal objective in medical education.[6] Teachings should not only focus on the development of moral reasoning and moral courage but should also attempt to explain why many “good” people sometimes don’t do the right thing.[7]
I wished that my pre-clinical years had better prepared me for what was a jarring transition from the controlled preclinical environment to the unpredictable clinical setting. Rather than questioning the team in real time or asking to debrief JA’s case, I chose to discuss the case months later with a thoughtful and trusted mentor, who highly values humanism in medicine, antiracism, and ethical practice. Those conversations inspired this reflection, which I hope will resonate with other trainees who have similarly been disappointed with their transition to clerkships and have struggled to find their voice in situations that felt wrong.
Essay 2 of 2: Teaching What Isn't Formally Taught: Moral Courage in the Face of Medicine's Hidden Curriculum by Krishna Chokshi
Ethics is a fundamental component of clinical practice, shaping physicians’ identities and guiding interactions with patients and colleagues. As educators, we aim to instill in learners the virtues of compassion, empathy, respect, and humility. Though we explicitly teach the attitudes, perspectives, and values of trustworthy and ethically minded physicians, we often fail to prepare them for the reality of clinical practice, where these ideals are eroded by competing demands and a medical culture that sometimes contradicts them. To navigate this dissonance, students must cultivate moral courage—the capacity to uphold ethical standards despite potential personal risk or discomfort—and learn from negative role models.
As preclinical students transition to clerkships, we must prepare them to confront scenarios where their values are challenged. Learners are usually indoctrinated into the realities of clinical practice through immersive experiences, often without formal guidance and support about how to navigate uncomfortable, unprofessional, or unethical behavior. Accepting this gap in education as a “reality” is morally injurious, especially as learners develop their professional identities during this critical phase. Both learners and seasoned clinicians need support as they grapple with the disconnect between aspirations and daily practice.
Studies highlight that many students witness or even participate in ethically troubling situations, such as violations of patient dignity or procedures performed without adequate consent. A 2015 study found that up to 60 percent of students were involved in situations where they felt they violated a patient’s dignity or participated in a procedure without the patient’s consent, at their instructor’s request.[8] Another study found that fewer than half of students feel empowered to speak up about unsafe or unethical behaviors, likely due to the hierarchical nature of clinical teams, fear of retribution, and self-doubt.[9] Over time, this environment may desensitize learners as they progress into residency.[10]
One student’s account of her first day in clerkships is a powerful testimony to how witnessing indignity burdens the conscience.[11] Negative attitudes towards patients, whether communicated through gossip or stigmatizing language, violate our basic duty of respect. The student experienced moral injury, which “results from traumatic ruptures between what people do and who they are.”[12] Burnout, emotional exhaustion, and loss of meaning in work often stem from feeling complicit in doing the wrong thing or constrained from doing what’s right. Our silence speaks volumes to the shameful aspects of medical culture we fail to challenge. Unfortunately, learning to be a doctor is intertwined with learning to ignore, accept, or feel defeated by the unethical behavior we normalize.
While what was said in the operating room was harmful, the student’s internal struggle about how to respond was likely more distressing. Fear of repercussions or not knowing what to say often silences students and clinicians alike. Our healthcare culture does not support such courage for learners, trainees, or even seasoned practitioners. In a large multicenter survey, nearly 30 percent of physicians were reluctant to question authority.[13] This silence not only fuels moral injury and burnout, but also compromises patient safety and care quality.
Amid a morally fraught clinical environment, ethics education has increasing importance. It should teach not only ethical principles but also the virtues of compassionate, trustworthy physicians.[14] In the student’s case here, ethical “rules” clearly indicate a violation of the patient’s privacy, but a virtue ethics approach highlights the clinical team’s failure to show care or respect. Their racist and callous words had a profound impact on the student, suggesting that her ethics education successfully imparted ethical sensitivity and self-awareness. The issue wasn’t insufficient humanistic education, but a lack of tools to cope with the disappointment of observing unethical behavior from her seniors.
Outside the formal curriculum, the informal curriculum (“how we do things here”) and the hidden curriculum (the tacit culture of values and norms they observe) may more strongly influence learners’ development in the clinical environment.[15] This “null curriculum,” that which is not formally taught, is influential. A 2016 medical school graduation questionnaire found that more than half of all students observed behaviors that contradicted what they had been taught about professionalism.[16] In this way, medical training may undermine empathy and ethical commitment, giving rise to moral distress.[17]
While negative role models contribute to the disconnect, contradictions between stated institutional values and actual practices deepen this tension. Learners often observe that though their academic institutions exalt health equity, they support several practices that contribute to health disparities, such as a two-tiered system, affording better services to patients with more socioeconomic privilege. The hidden curriculum is evident not only in clinical interactions but also in how academic healthcare institutions treat patient communities and uphold – or fail to uphold – their mission statements.
While negative role models are problematic, they offer critical learning opportunities. Witnessing unethical behavior helps students define their moral boundaries and deepen their commitment to ethical practice. These uncomfortable experiences clarify personal values and sharpen ethical convictions.
Still, ethics education often fails to equip students to act ethically under pressure. We teach students to identify ethical issues but not to navigate the emotional and professional complexities of acting on them. Embedding moral courage as an explicit competency is essential. We must expose the hidden curriculum to counteract its effects. Educators should encourage students to feel comfortable speaking up - that is, to develop moral courage, the ability to do the right thing or not do the wrong thing, even in the face of competing self-interests. In this example, the student’s role was to be a learner, not a “watchdog” of good behavior. Speaking up in the moment, as she reflected, may have been perceived as arrogance or self-righteous behavior. The student did nothing wrong by remaining silent, but she needed a space to reflect with trusted role models. The learning environment did not support her enough. Was she given the chance to explore what this experience meant for her professional identity?
Despite widespread ethics instruction, defining goals and measuring the impact of such education remains a challenge, resulting in heterogeneous approaches across academic institutions.[18] Most curricula emphasize ethical knowledge and frameworks. Instructors may present clinical cases for analysis, but it is harder to foster reflective practice and real-world application. Small group, case-based learning supports this reflection, and these spaces can also promote leadership skills and confidence, skills that are necessary for moral courage.
Investing in the moral courage of our students will improve the culture and moral habitability of our organizations for physicians, learners and staff, and the quality of healthcare for our patients. Moral courage involves calling out harmful behaviors in others and in ourselves and is essential for cultivating future physicians who advocate for their patients and a more just system. Not surprisingly, few students feel comfortable critiquing someone else’s behavior compared to rectifying their own.[19] Learning to provide respectful and constructive feedback, however, is a lifelong professional skill and critical to reforming our troubled healthcare system.
How can medical educators foster environments that build moral courage?
- Acknowledge the Hidden Curriculum: Be transparent about ethical challenges students will face - pressures to conform, the normalization of unethical behavior – so students are prepared and can develop strategies to resist.
- Structured Reflection: Reflection helps students process difficult clinical experiences and understand their ethical values. Use narratives, discussions, or writing prompts to deepen ethical insight.
- Safe Spaces for Ethics Discussion: As students encounter more clinical situations, they need ongoing forums to explore ethical dilemmas. Role-playing, real-world case discussions, and debates in safe spaces without fear of judgment can foster readiness and courage.
- Active Role Modeling and Mentorship: Educators should demonstrate moral courage and reflect openly on their own experiences with ethical challenges. When students see their mentors take a stand for what is right, they are more likely to emulate this behavior. Longitudinal mentorship helps guide students through identity formation and moral growth and allows students to seek guidance when faced with moral dilemmas.
- Skill Development: Teach students how to speak up through structured training (i.e., role-playing or with standardized patients), just as communication skills are taught.
- Anonymous Reporting Mechanisms: Minor transgressions often go unreported, yet they shape toxic culture. Involve students in designing transparent and effective reporting systems.
Our learners will inevitably encounter moments where they struggle to do the right thing – whether that requires calling out a colleague, advocating passionately for a patient, or confronting their own moral commitments. Just as we train our learners to communicate clinical information effectively and compassionately, we need to prepare them to not only identify ethical action, but to also consider what acting ethically requires of themselves. Empowering learners to take ethical action – not just recognize it – is transformative. The development of moral courage should be a core competency in ethics education. To achieve this, we must shift from asking “What is the right thing to do?” to “How will you do the right thing?”
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[1] Galit Neufeld-Kroszynski, Keren Michael, and Orit Karnieli-Miller, “Associations between Medical Students’ Stress, Academic Burnout and Moral Courage Efficacy,” BMC Psychology 12 (May 27, 2024): 296, https://doi.org/10.1186/s40359-024-01787-6.
[2] Catherine V. Caldicott and Kathy Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third-Year Medical Students,” Academic Medicine: Journal of the Association of American Medical Colleges 80, no. 9 (September 2005): 866–73, https://doi.org/10.1097/00001888-200509000-00018.
[3] Catherine V. Caldicott, “Revisiting Moral Courage as an Educational Objective,” Academic Medicine: Journal of the Association of American Medical Colleges 98, no. 8 (August 1, 2023): 873–75, https://doi.org/10.1097/ACM.0000000000005239.
[4] Caldicott and Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal”; “Measuring Moral Choices by Physicians: Standing up for Patients,” American Medical Association, August 3, 2016, https://www.ama-assn.org/delivering-care/ethics/measuring-moral-choices-physicians-standing-patients.
[5] “Measuring Moral Choices by Physicians.”
[6] Caldicott and Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal.”
[7] Caldicott, “Revisiting Moral Courage as an Educational Objective.”
[8] Lynn V. Monrouxe et al., “Professionalism Dilemmas, Moral Distress and the Healthcare Student: Insights from Two Online UK-Wide Questionnaire Studies,” May 1, 2015, https://doi.org/10.1136/bmjopen-2014-007518.
[9] Neufeld-Kroszynski, Michael, and Karnieli-Miller, “Associations between Medical Students’ Stress, Academic Burnout and Moral Courage Efficacy.”
[10] Alastair V. Campbell, Jacqueline Chin, and Teck-Chuan Voo, “How Can We Know That Ethics Education Produces Ethical Doctors?,” Medical Teacher 29, no. 5 (January 1, 2007): 431–36, https://doi.org/10.1080/01421590701504077.
[11] Katharine R. Meacham, “Preventing Moral Injury in Medicine: Student Physician Stories of Moral Distress, Alienation, and Moral Imagination,” Public Philosophy Journal 2, no. 2 (2019), https://doi.org/10.59522/WHEQ3650.
[12] Katharine R. Meacham, “Preventing Moral Injury in Medicine: Student Physician Stories of Moral Distress, Alienation, and Moral Imagination,” Public Philosophy Journal 2, no. 2 (2019), https://doi.org/10.59522/WHEQ3650.
[13] Linda H. Aiken et al., “Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety,” JAMA Health Forum 4, no. 7 (July 7, 2023): e231809, https://doi.org/10.1001/jamahealthforum.2023.1809.
[14] David J. Doukas et al., “Virtue and Care Ethics & Humanism in Medical Education: A Scoping Review,” BMC Medical Education 22, no. 1 (February 26, 2022): 131, https://doi.org/10.1186/s12909-021-03051-6.
[15] Lisa Soleymani Lehmann et al., “Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians,” Annals of Internal Medicine 168, no. 7 (April 3, 2018): 506–8, https://doi.org/10.7326/M17-2058.
[16] “Medical School Graduation Questionnaire: 2016 All Schools Summary Report” (Association of American Medical Colleges, July 2016), https://www.aamc.org/media/8321/download.
[17] Doukas et al., “Virtue and Care Ethics & Humanism in Medical Education.”
[18] Rachael E. Eckles et al., “Medical Ethics Education: Where Are We? Where Should We Be Going? A Review,” Academic Medicine: Journal of the Association of American Medical Colleges 80, no. 12 (December 2005): 1143–52, https://doi.org/10.1097/00001888-200512000-00020.
[19] Neufeld-Kroszynski, Michael, and Karnieli-Miller, “Associations between Medical Students’ Stress, Academic Burnout and Moral Courage Efficacy.”
