Skip to main content

When doctors cheat

By Gregory W. Ruhnke
updated 7:39 AM EST, Mon December 9, 2013
STORY HIGHLIGHTS
  • Doctors were disciplined for sharing examination questions
  • Gregory Ruhnke says cheating is surprisingly common among medical students
  • He says cheating fosters behavior that can persist through doctor's career

Editor's note: Gregory W. Ruhnke, MD, MS, MPH is an assistant professor in the Section of Hospital Medicine in the Department of Medicine at the University of Chicago.

(CNN) -- In 2010, the American Board of Internal Medicine suspended or revoked the certification of 139 physicians for giving away or soliciting examination questions for a board review company.

CNN subsequently reported on residents preparing for certification examinations using questions reproduced by people who took previous exams.

Residents taking the American Board of Radiology medical physics examination wrote down test questions ("recalls"), and shared them with future examinees. Dermatology residents also reproduced questions ("airplane notes") minutes after the certification examination.

Gregory Ruhnke
Gregory Ruhnke

Question reproduction violates copyright policies. However, some physicians CNN interviewed said that recall use is like preparing with a study guide since questions are used to confirm underlying knowledge, not rote memorization of answers.

Consistent with this view, only 43% of medical students surveyed at a UK medical school thought it was clearly wrong to convey information about test content to another student examinee.

However, such behavior should create concern for the quality and integrity of patient care. Medical students who cheat on examinations are more likely to falsify information in a patient's medical record. Patients want physicians to be certified based on a valid assessment of the knowledge necessary to provide high-quality care. If patients cannot trust the knowledge that board certification is expected to measure, the medical profession loses the public's confidence.

Moreover, certification should indicate the ability to care for patients, rather than efficient test preparation. Notably, although patients express a highly favorable view of certification, it is not required by most hospitals and health care plans.

Prescription for Cheating investigation

The distinction between cheating and guided study is crucial. Old test questions and recent examination experience are routinely used to create study materials. The American College of Physicians produces a summary of concepts and information most likely to appear on the ABIM certification exam. The content of this summary is shaped by post-examination residents. The First Aid series for medical students is updated annually based on examinee reports.

Using a focused study guide created based on examinees' input bears some similarity to studying from practice questions that may have been on a recent examination. The difference lies in the detail and specificity of the information conveyed. Nevertheless, from the public's perspective, both practices represent "shortcuts" for examination success.

Drivers of dishonest behavior

Cheating in education and sports creates unfairness between "competitors." Unlike performance-enhancing drugs, the use of Ritalin and Valium to improve test performance is not considered cheating. Difficulty concentrating and anxiety are perhaps considered abnormal disadvantages from which examinees deserve sparing.

The unfairness perspective is reflected in a dean's observation in the CNN report -- since use of reproduced questions is so pervasive, this norm does not cause any unfair advantage. Unfortunately, 57% of surveyed medical students claimed that others' cheating had unfairly disadvantaged them.

The difficult content of the radiology physics exam is one reason for the use of reproduced questions. For most physicians, the exhaustive study of biochemistry and pharmacology is a rite of passage based on knowledge rarely used.

In fact, the physicians interviewed by CNN said that the necessity to demonstrate proficiency of arcane material unimportant for practice was a root cause of residents using reproduced questions for exam preparation. In other words: Test content that medical students view as unnecessary for clinical care makes them more likely to cheat.

Of course, a desire to succeed underlies the decision to cheat: 40% of 665 medical students across six schools admitted to doing something unethical to avoid a poor evaluation. However, fear of failure is not generally sufficient -- social context is important.

Academic dishonesty is strongly connected to peer behavior. Many medical students believe certain forms of cheating can be justified if the motivation is to assist friends. Of 2,459 medical students from 31 schools, 41% had cheated during high school and 59% thought that cheating was too common to eliminate. When misconduct becomes an established norm, as it apparently has among certifying residents, it does not become acceptable, but can be difficult to stop.

How to limit unethical behavior

The use of reproduced questions for board examination preparation threatens medicine's integrity and public trust. Moreover, indisputably dishonest behaviors are far too common among trainees.

Punishments and honor codes do little to reduce academic dishonesty in medical education. Responses to unethical acts have also been hampered by divergent opinions about the severity of specific violations and appropriate punishments. However, peer behavior has a strong impact on ethical decisions. The image of dermatology residents writing down test questions together in a restaurant suggests this has become an established norm. Trainees find it more acceptable to engage in unethical conduct when their friends are as well.

The best way to limit unethical behavior is to embed academic honesty into institutional cultures, perhaps through role models and curricula that emphasize the respect that a virtuous professional may earn.

Case-based ethics training may improve moral reasoning, although the impact on conduct is unknown. Examination content must be highly relevant for the patient-care activities that will be endorsed. Esoteric questions suggestive of academic hazing should be eliminated.

Not reusing test questions would reduce the incentive to reproduce questions in verbatim form, but might jeopardize the consistency of passing standards, while increasing expenses.

In the end, successful certification must demonstrate that physicians are vested with the trust of both their peers and the public. Sponsoring rigorous examinations that cover material critical for patient care will bolster what the profession provides patients.

Ultimately, the integrity of the medical profession and the faith that patients place in physicians demand the highest moral standards.

Follow us on Twitter @CNNOpinion.

Join us on Facebook.com/CNNOpinion.

The opinions expressed in this commentary are solely those of Gregory Ruhnke.

ADVERTISEMENT
Part of complete coverage on
updated 3:47 PM EDT, Wed October 1, 2014
Julian Zelizer says Jimmy Carter's message about the need to restore trust in public officials is a vital one, decades after the now 90-year-old he first voiced it
updated 5:56 PM EDT, Wed October 1, 2014
Ford Vox says mistakes and missed opportunities along the line to a diagnosis of Ebola in a Liberian man have put Dallas residents at risk of fatal infection
updated 6:21 PM EDT, Wed October 1, 2014
Pepper Schwartz says California is trying, but its law requiring step-by-step consent is just not the way hot and heavy sex proceeds on college campuses
updated 10:17 PM EDT, Wed October 1, 2014
Mike Downey says long-suffering fans, waiting for good playoff news since 1985, finally get something to cheer about
updated 5:39 PM EDT, Wed October 1, 2014
Steve Israel saysJohn Boehner's Congress and the tea party will be remembered for shutting down government one year ago
updated 2:56 PM EDT, Wed October 1, 2014
Yep. You read the headline right, says Peter Bergen, writing on the new government that stresses national unity
updated 7:12 PM EDT, Wed October 1, 2014
Hong Kong's pro-democracy demonstrators are but the latest freedom group to be abandoned by the Obama administration, says Mike Gonzalez
updated 12:53 PM EDT, Tue September 30, 2014
Jeff Yang calls Ello a wakeup call to Facebook and Twitter, and a sign of hope for fast-rising upstarts Pinterest and Snapchat.
updated 10:23 AM EDT, Wed October 1, 2014
Paul Waldman says the Secret Service should examine its procedures to make sure there are no threats to the White House--but without losing the openness so valuable to democracy
updated 10:55 AM EDT, Wed October 1, 2014
Jesse Williams says the videotape and 911 call that resulted in police gunning down John Crawford at a Walmart reveals the fatal injustice of racial assumptions
updated 7:03 PM EDT, Tue September 30, 2014
Mel Robbins says officials should drop the P.C. pose: The beheading in Oklahoma was not workplace violence. Plenty of evidence shows Alton Nolen was an admirer of ISIS.
updated 3:11 PM EDT, Tue September 30, 2014
The Occupy Central movement has already achieved much by bringing greater attention to Hong Kong's struggle for democracy, William Piekos says..
updated 3:11 PM EDT, Tue September 30, 2014
The Occupy Central movement has already achieved much by bringing greater attention to Hong Kong's struggle for democracy, writes William Piekos.
updated 10:13 AM EDT, Tue September 30, 2014
As Prime Minister Narendra Modi visits America, Madeleine Albright says a world roiled by conflict needs these two great democracies to commit to moving their partnership forward
updated 10:04 AM EDT, Tue September 30, 2014
John Sutter: Lake Providence, Louisiana, is the parish seat of the "most unequal place in America." And until somewhat recently, the poor side of town was invisible on Google Street View.
updated 9:11 AM EDT, Mon September 29, 2014
Julian Zelizer says in the run up to the 2016 election the party faces divisions on its approach to the U.S.'s place in the world
updated 10:19 AM EDT, Mon September 29, 2014
Ruben Navarrette says Common Core supporters can't devise a new set of standards and then fail to effectively sell it.
updated 9:29 AM EDT, Tue September 30, 2014
Earlier this month, Kenyans commemorated the heinous attack on the Westgate Mall in Nairobi.
updated 2:59 PM EDT, Tue September 30, 2014
David Wheeler says Colorado students are right to protest curriculum changes that downplays civil disobedience.
updated 9:58 PM EDT, Fri September 26, 2014
Sally Kohn says when people click on hacked celebrity photos or ISIS videos, they are encouraging the bad guys.
updated 7:55 AM EDT, Fri September 26, 2014
Loren Bunche says she walked by a homeless man every day and felt bad about it -- until one day she paused to get to know him
updated 9:32 AM EDT, Tue September 30, 2014
ISIS grabs headlines on social media, but hateful speech is no match for moderate voices, says Nadia Oweidat.
updated 8:33 AM EDT, Mon September 29, 2014
A new report counts jihadists fighting globally. The verdict? The threat isn't that big, says Peter Bergen.
updated 5:37 PM EDT, Tue September 23, 2014
Ebola could become the biggest humanitarian disaster in a generation, writes former British Prime Minister Tony Blair
updated 12:58 PM EDT, Fri September 26, 2014
ISIS has shocked the world. But will releasing videos of executions backfire? Four experts give their take.
updated 10:39 AM EDT, Fri September 26, 2014
Eric Holder kicked off his stormy tenure as attorney general with a challenge to the public that set tone for six turbulent years as top law-enforcement officer.
updated 9:09 AM EDT, Fri September 26, 2014
LZ Granderson says Obama was elected as a war-ending change agent, not a leader who would leave behind for his successor new engagement in Iraq and Syria. Is he as disappointed as the rest of us?
updated 5:10 AM EDT, Wed September 24, 2014
Gayle Lemmon says the question now is how to translate all the high-profile feminizing into real gains for women
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT