White coats, white lies? Or black marks?

In which Dr Aust ponders what one should do about students who are ‘economical with the actualité’.

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One of my scientific internet friends, Steve Caplan, was blogging a week to two back about a student in a lab he worked in who was, shall we say, less than truthful about their actions.

Steve says at one point, recounting what he said to the lab boss about the student:

“Imagine if s/he lied about little things like salt buffers [experimental reagents], what kind of data s/he might have fabricated later on,”

Which caught my attention – partly because research misconduct, and what should be done about it, is in the news at the moment.

But also partly because it deals with a regular part of University life – that problematic character, the student whose habits give cause for concern.

Much of the debate about student conduct recently has tended to focus on plagiarism, but here I am not talking about that, or even what one might call “academic misconduct’. I am talking about the more subtle things to do with how people behave, and how they interact with their colleagues.

Apart from in the lab, another place this turns up  – and perhaps a slightly special setting – is medical school. There is a long-standing debate about how sub-standard conduct should be dealt with, and what behaviours students should be ‘pulled up’ for – especially for students in the pre-clinical years where we have historically tended to take a more relaxed view of how students should behave than our clinical colleagues.

[The main point was that in the past students did not see patients until their third year of medical school. Nowadays in many courses they are around hospitals and GP clinics from the very start of their student career. So they are under the microscope rather more than was formerly the case.]

One argument for what one might call a “Zero tolerance” policy is studies like this one, in the New England Journal of Medicine a few years back.

Of course, the counter-argument, which also has force, is the ‘youthful high jinks’ one – that is, that everyone does daft, or even idiotic, things, and behaves like a plonker, when young, and mostly people grow out of it. For some medical examples you could try many a medical memoir – or for a recent political example you could try Louise Mensch MP’s robust riposte to the Daily Mail a couple of weeks back. There has even been a discussion in the medical literature of whether previous criminal convictions – which one could call an extreme example of idiotic behaviour – should be an absolute bar to entering medical school.

On the whole, when we hear about misbehaviour by students, we tend to try and distinguish between “stupid stuff” (they really don’t know);  and “worrying stuff” (they know, but do it anyway) – of which the most worrying is usually “dishonest stuff”.

A couple of examples of the latter.

In our lab classes for medical students we teach them stuff that they are later tested on, like using peak flow meters and spirometers, and measuring blood pressure. The test they get on this later is in the form of a what is called an OSCE, a kind of practical exam in which students pass through a series of “stations’ where they have typically 5 or 6 minutes to do a task – like measure a volunteer subject’s blood pressure.

As well as teaching students these skills in scheduled classes, we run revision classes a couple of weeks before the OSCE takes place.

Now, the people who teach these revision class are adamant that these classes are for revision – NOT for teaching the skills from scratch to students who couldn’t be arsed to turn up to the regular scheduled sessions earlier in the semester. So the rule for students is that, if you have missed more than 20% of the semester’s scheduled lab classes without explanation, you cannot come into the revision session,

Though this is well publicised, it sometimes seems to come as a shock to less, errm, organised students.

A good few years ago now, a couple of my colleagues were checking the students in at the door on such a revision class when a student appeared who the records showed had exceeded the allowed number of absences. They pointed this out to him and said he would not be allowed in.

“Oh no” said the student “I gave in notes explaining that absence and that absence” (this would get him into the revision class, as ‘excused for something you couldn’t help’, like a doctor’s appointment or illness, or some other stuff, usually doesn’t count as ‘absent without reason’).

Now, one of my colleagues was a touch suspicious, trotted off to the Faculty Office that ‘logs’ such notes, and checked what the student had said.

The student had handed in nothing for the dates in question. No notes. No reasons for the absences.

The student was told to leave the class, and was, I am pretty sure, reported to the Course Director for what in the old days would have been called ‘a right bollocking’.

It was not the being absent from the earlier classes that was the most worrying thing, but rather that the student had flatly and directly fibbed (about the notes for his absences) to a member of the academic teaching staff.

I am curious to know what my readers, especially the medical ones, make of this.

Now, Mrs Dr Aust, the family’s medical expert, has little (read: “no”) sympathy for the student in this story. She is suspicious as to whether leopards change their spots, for one thing. And she says that people who will lie, or even just bend the truth a bit, to get themselves off the hook are a flat-out liability in medicine, full stop. The standard scenario she tends to give is one like this:

In an urgent diagnostic discussion about patient Mr X, gets-by-on-charm-but-a bit-of-an-idler junior doctor Dr Y is asked by a more senior colleague about the result of test Z that he, Dr Y, was supposed to have ordered yesterday. Dr Y had forgotten to order the test. However, fearing a public kicking, he does not admit this but says instead ‘ Errm… the result’s not back yet’.

Of course, you can argue that that latter scenario is unrealistic. But Mrs Dr Aust says that this happened sufficiently frequently to her over the years that eventually she took to phoning the lab herself when she heard this line – to be told, on more than one occasion: “Nope, there’s no sample”.  She also says that there were junior doctors who, when confronted about this, would respond with anger rather than holding their hands up. She says one even called her ‘A Fascist’.

You can also argue that this kind of behaviour is a long way from the skiving student-in-the-lab-class example that I gave above.  But, and this is the crux of the matter,  there is always a suspicion that people who are prepared to lie about one thing are more likely to be prepared to lie about other stuff too.

And there is also a sense that, the more they get away with it, the more they will carry on doing it.

So where should we draw the line? 

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The day after I wrote the first version of the above, I was reminded by a discussion on Twitter about something else in a similar vein (artery?).

In our practical tests of measuring blood pressure, which is one of the skills we teach to students, the examiner almost always listens to the same Korotkoff sounds that the student hears via a dual stethoscope.

One of the things you regularly experience as an examiner for this is the student who, when no sounds whatsoever have been audible – typically because the stethoscope bell is in the wrong place – announces:

“One twenty over eighty”

(i.e. a blood pressure of 120/80 mm Hg, which is normal and thus a good random guess for an adult – though it is usually a little high for a fit younger adult, like most of our volunteer subjects tend to be. Of course, we take their BP at the start of the day and periodically thereafter, so we know what their BP is really likely to be).

We were talking about this today, and the thought occurred to me: is offering that answer, when you could not possibly have got a reading of blood pressure, actually – or at least arguably – an attempt to deceive?

And – it would be a pretty draconian way to do it, but should we automatically fail anyone who says it?  

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Postscript:

Just to expand on this a bit:

There is always a kind of tension in professional degrees between the need of students repeatedly to pass exams to progress on the course, and the ultimate need for them to learn to do certain things (like measuring blood pressure). One is regularly told (and it is a reasonable axiom) that ‘assessment drives learning’. So if you have a test where there is no downside to guessing (apart from not getting the mark you would get for getting the right answer), students will guess.  [Many University multiple choice exams use what is called ‘negative marking’ specifically to give students a downside to guessing at random when they don’t know the answer].

But in the setting I have described, there are several problems with this.

One is the problem described above – you could say we are allowing the students to assume it is OK to make up an answer, when really it shouldn’t be.

Two is that it is of course important to be able to measure blood pressure accurately; the students should, in turn, be able to see that it is important that they learn to do it properly. If you are being really earnest, you might say they should be able to see that ‘fronting it’ (doing a third rate version but trying to look super-confident) is not really on.

Three is that you could say this represents a lost opportunity – perhaps the students should be pulled up straight away and asked to expand on why they had trotted out a number when there were no sounds.

The point there being to get them to think about why there might be problems with what they had just done that might make it more than just the equivalent of a random guess in a multiple choice exam.

After all, if behaviours that are not acceptable are not identified and challenged, how do the students actually learn…. that the behaviours are not acceptable?

Or – am I just being a hopelessly crusty old git? Highly possible, after all. I am undeniably middle-aged. And famously curmudgeonly.

Anyway – opinions, anyone?  I know it’s a bit cheeky asking for views when it’s been so long since the last post, but I would be interested in what the readers, young and old(er), think.

 

PS – I should also say that, though I’ve been around medical schools a long time, I don’t pretend to claim any great expertise in assessment. Far greater minds than mine etc etc.

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