Education
Canadian Medical Association Journal 1997; 156: 219-222
[en bref]
© 1997 Canadian Medical Association (text and abstract/résumé)
Programs are becoming increasingly competitive as the number of residency positions is reduced, and it is more difficult for students to obtain a position in the program of their choice. There is a need to apply not only to desired programs but also to less-popular ones that serve as "back-ups" should applicants not be granted their first choice.
Although the consequences of matching to a less-desirable program are serious, they are usually more favourable than being left unmatched. Thus, medical students are applying to more programs than they did in the past and are more likely to consider more than one specialty option.1,2 [Indeed, in October CMAJ reported that one "cautious couple" had submitted paired rankings and ranked 104 program choices for the 1996 match. In a survey of 1995 graduates of Canadian medical schools, respondents applied to an average of 2.4 disciplines and 13.1 programs through the Canadian Resident Matching Service (CaRMS).3 — Ed.]
During the selection process, applicants must convince program directors that they are committed and keen to fulfil the necessary obligations of their specific program. The application package will be padded with convincing evidence supporting the applicant's desire to enter that particular program. Applicants compose personal letters that not only describe themselves as budding physicians whose experiences, personalities and goals make them a perfect fit for the specific program's ideals, but which also explicitly state a desire to enter the specialty to which they are applying.
In order to have the best chance at obtaining a spot, students attempt to be perceived as the most desirable candidate for a particular program and discipline. In reality, applicants usually put together more than one application package, each of which is custom tailored to match the nature, requirements and goals of a given program or specialty.
For example, applications sent to ophthalmology programs may reflect a candidate's true and primary desire to be an ophthalmologist, and the personal statements and letters of reference collected from staff ophthalmologists will also support this desire. Yet the application from the same student to his or her "second-choice" specialty will make equally convincing arguments that the budding physician's primary and true desire is this second specialty. The personal statement will differ, as will the reference letters, which are now from staff in this second field. Honesty is never an issue — the emphasis is on avoiding failure and achieving success.
When considering the use of deception in the resident-selection process, students feel coerced into lying so that they won't jeopardize their future career. My own informal survey of 10 medical students who had recently completed the application process showed they believed that their lies were beneficial and prevented harm by allowing them to appear as more desirable candidates to different programs. They argued that being completely honest would have hurt their chances.
It is disconcerting that medical students openly resort to the use of deception, dishonesty and outright lies in the resident-application process. Those who apply only to programs within 1 discipline must also explicitly or implicitly lead their interviewers to believe that they are interested in the program they are being interviewed for, even if they have no intention of ranking it anywhere near the top of their list of choices. In the 1995 CaRMS postmatch survey, 32.7% of respondents were asked how they planned to rank their programs.3 An applicant driven to obtain a desired residency position would not likely tell the truth in answering that question during an interview with a program director. The inherent deception in the selection process is widely practised and unquestioningly accepted by everyone involved.
The blatant contradiction between the ideals of the medical profession and the unacknowledged deceit that exists during the selection of future doctors is perturbing. There is something morally reprehensible about a process in which inherent dishonesty is needed in order to succeed or avoid disastrous consequences. I am not referring to the punishable offences of falsifying documentation or resorting to verbal falsehoods about one's experiences: dishonesty is evident at a less culpable and even admissible level during the admissions process, and it is considered not only an acceptable but also a required standard of practice.
"An ethical physician will recognize that the profession demands integrity from each physician and dedication to its search for truth and to its service to mankind.""[A physician] will behave in such a manner as to merit the respect of the public for members of the medical profession."5
Dr. John Williams, the CMA's director of ethics and legal affairs, has stated that "every word in it is important because the code is a synthesis of everything Canadian physicians are supposed to do."6
The American Medical Association's Principles of Medical Ethics are similar to the CMA code. One principle states that "a physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception."4
In general, intentionally misleading others about the truth with outright statements (lies) or with indirect gestures (deception) is morally wrong.7 A deceived person assumes that the presented facts and impressions are truths, and trust breaks down upon realization of the deceit. Truthfulness is essential for society to function because honesty lets those involved in making a decision make informed choices.
The trust that honesty engenders among people serves to strengthen and provide a basis for building meaningful relationships. If words and gestures cannot be counted on actions and statements will have no value, and without meaningful communication society will collapse. People would be unable to make informed decisions because there would be no reliable information. Thus, dishonesty has the potential to damage relationships that have been built on trust.7
Moral rules are general rules, valid at best only at first appearance and open to variance. They are guidelines, not rigid rules.8 Medical students and those who guide them in the admissions process stand by this tenet to defend their dubious actions during the resident-selection process. In the difficult and sometimes desperate situation of applying for a limited number of residency positions, one may doubt whether moral or ethical standards are relevant. In certain life-threatening situations it may be impossible to adhere to any moral principles, such as truth-telling, but it appears that the medical profession has applied this exemption to its training process. The profession has accepted that dishonesty is necessary because of the dire consequences of being truthful.
If program directors discover that an applicant has lied about his or her intentions and interests, they may not believe another applicant who may in fact be stating the truth in a later interview. Directors can never be certain that what students say is the truth and this mistrust may have consequences for an applicant's file. Thus, in the wake of damaged trust spoken intentions become questionable. The interviewer is compelled to rely upon what he or she perceives to be more sturdy evidence, whether it be objective (grades) or subjective (personality).
By discounting statements made during an interview, program directors may be missing opportunities to learn something unique about an applicant that not only might help the applicant's chances but also may help strengthen the residency program. Ironically, dishonesty may not even benefit the applicant who uses it because of the mistrust established by predecessors who have advised the applicant to lie.
And what happens if an applicant should match to a program of last resort? In that case the earlier deception may manifest itself as a lack of interest or poor performance that can affect both professional relationships and patient care. In the end, the practice of dishonesty may serve no one well.
Deceptive practices may also erode the moral behaviour of Canada's future physicians. The most troubling fact is that it appears dishonesty in the application process has been universally and unequivocally accepted. To my knowledge, this issue has not been addressed in the medical literature, and being dishonest appears to have been brushed off as a mere necessity, a fact of life. Students are being taught that obtaining a residency position is a competitive venture in which the truth not only can but also must be compromised. No one even acknowledges that a moral dilemma exists.
Competition does not begin or end with resident selection. Elements of competition and crisis exist throughout a medical career, and there may be further evaluations and interviews that have implications for career advancement and employment opportunities. There are also unavoidable issues in patient management that have the potential to cause setbacks. If we fail to acknowledge the existence of a moral problem early in our careers and remain unaware of the ethical compromise involved in resident selection, what will we do in the future? Will we believe that unethical behavior is justifiable in the face of competition and crisis?
It is ironic that our profession advocates honesty but has institutionalized dishonesty. Are future physicians to be guided by ethical standards or by what they are implicitly encouraged to do? When today's students are physicians, will they be more or less likely to tell the truth after having learned how to lie to their advantage during the resident-selection process? The answers to those questions hold potential implications for both physicians and the public.
The confidential nature of the CaRMS process, which denies program directors access to information concerning other programs to which an applicant has applied, might be altered. The handbook sent to applicants states that the CaRMS "provides a judgement-free service under which decisions can be made confidentially and without pressure."9
As things stand, an artificial but legitimate consequence-free environment has been created that shields applicants' true intentions from program directors. Thus, they are free to hide their true intentions and to present only the information that will enhance their application. The confidentiality of the process ensures that none of their deceptive practices will be discovered. Although CaRMS does provide a tremendously valuable coordinating service that links programs and applicants, the implications of its confidential, nonpressured and judgement-free application process only serve to foster dishonesty. As one medical student told me, "It certainly makes it easier to hide one's intentions."
When there is so much at stake, it is difficult for applicants to recognize the existence of a moral problem and to question their own moral conduct. Because this practice has been condoned, encouraged and institutionalized, students feel little need to examine their actions.
In theory lying and deception are unacceptable and the truth must be upheld, but in practice these rules do not apply. Everyone involved in resident selection must begin to acknowledge and realize the potential implications of the institutionalized dishonesty that has become an integral part of the selection process. Only then can steps be taken to reform the process.