consents instead of residents or writing progress notes and charts for others), especially in situations in which the students’ performance ratings and credentials are at stake?

  • How should students challenge inappropriate or even offensive treatment of patients observed in clinical work situations when they are on the lowest rung of the medical decision-making ladder?

  • Should students introduce themselves to patients and families as medical students, recognizing that patients may assume that anyone in a white coat is a fully credentialed medical doctor?

These are examples of clinical ethical quandaries that students must resolve, sometimes on their own. All of these value-laden situations demand clear reasoning, an understanding of underlying personal and professional values and basic first principles, well-developed communication skills, and even group leadership skills.

Medical schools have used numerous pedagogical approaches to address such issues. Many of these teaching and learning approaches—such as the use of problem-based cases, small-group exercises, interaction with standardized patients, reading and discussion of materials drawn from the humanities, discussions during clinical rounds, and opportunities to talk with and obtain feedback from senior personnel—are discussed in Chapter 2.

The education for a virtuous life in medicine does not, of course, begin or end in medical school, as many of the scholastic issues faced by medical students (e.g., cheating and plagiarizing) arise earlier. However, medical students first experience the distinct challenges of clinical responsibility in preceptorships and clerkships when they begin to care for patients.

Personal Values, Attitudes, and Biases as They Influence Patient Care

Physicians’ attitudes guide their behaviors, and these attitudes are in turn shaped by a variety of factors, including personal histories, family and cultural backgrounds, values, biases, and emotions. Both unrecognized and recognized feelings and attitudes can adversely affect physician–patient communication (Stein, 1985) and may emerge inappropriately during the medical encounter, endangering the physician–patient relationship (Bennett, 1987).

Assuming that physicians develop adequate levels of knowledge and skill through their training, it will be their attitudes that ultimately determine the quality of the care they provide. This includes attitudes about the importance of psychosocial factors in medical care and about the importance of self-sufficiency, personal responsibility, family values, aging, racial and ethnic differences, and death, all of which shape the physician–patient interaction (Carmel, 1997; Cheng et al., 1999; Ely et al., 1998; Epstein et al., 1993; Nightingale et al., 1991; Novack et al., 1997; O’Loughlin et al., 2001).

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