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Posted on March 27, 2018 at 10:10 AM

By Tim Lahey

Every March I run the last required course at our medical school. It’s a three-week-long, 47-hour sprint – a sort of boot camp for professional formation. We polish clinical skills, revisit foundational sciences, let students pick from a menu of interesting tutorials, and discuss professional formation.

Students grapple with hypothetical gastrointestinal crises on scatalogically-named student teams. They resuscitate rubbery patients with various flavors of hypotension. I don a sparkly red bowtie to MC a game show called Antibiotic Jeopardy.

Throughout, we discuss the evolution of their professional identities. I ask how their idealism has changed during medical school, and every year over 60% say it has waned. We share the stories that shape us, and how they can stay true to the values that brought them to medical school in the first place. Then they hand in a tall stack of confidential essays that I reply to on nights and weekends right up until the day they speak the Hippocratic Oath. 

This is a special class. They knock my socks off with their insight, and vulnerability.

The course also includes the routine mechanics of instruction. PowerPoint slides are exchanged. Scheduling conflicts come up. Audiovisual meltdowns occur.

Recently, I got an email that felt routine at first. Then I started to think it, too, was about professionalism.

The student wrote, “I’m wondering if I can get an extension on the due date for the complete physician essay.” He was attending an optional scientific conference out of town and hoped he could have more time to complete the assignment. It was due in 10 hours, and the conference was busier than expected.

Here’s my response:

I have a complicated answer to your question, sent with a smile.

The short version:

You won’t fail [the course] if you blow this deadline, and it’s not a big deal, but I want you to think through whether it is wise to ask me this.

The longer version:

For the rest of your life, your professionalism will be judged on how well you keep promises and execute on your obligations without fuss. Sometimes there’s an explicit deadline like this, but usually your reputation is made of small moments like this one. Did you call the patient back? Did you reply to colleagues’ emails? Did you carry your weight on a paper, or on a committee? Since those are small moments, people decide what they think of you – and ultimately I think you decide what you think of you – in mostly implicit ways. Meaning, you probably never hear back if you’ve lost reputational currency until colleagues refer their patients to someone else or a promotion doesn’t come or someone else gets the plumb teaching assignment.

Here, you are asking fewer than 12 hours before a deadline if you can blow the deadline on a required assignment in order to participate in an optional event. It’s a request I wouldn’t make.

I either execute (99% of the time), or fail to execute but apologize and accept the consequences (0.99%) or something truly unavoidable comes up like a medical illness or a death in the family in which case I fail and apologize but ask for clemency (0.01%). What you are doing is both failing to execute and failing to take responsibility for it, which isn’t one of the options I’d suggest you allow yourself.

I thought about just saying, ‘Sure, no big’ because it’s really not. But then I figured I wouldn’t be holding up my end of the bargain. This is, after all, an essay on your professionalism, and this is a moment in your professionalism.

Hope that is thought-provoking, and that you are having a good time there, and whatever you do, I’m off my soapbox and back to :).

What do you think? Did I make a professionalism mountain out of a logistical molehill? How do you try to support your students’ professional formation?


Tim Lahey, MD MMSc, is an HIV and infectious diseases physician and clinical ethicist at Dartmouth-Hitchcock Medical Center and Dartmouth’s Geisel School of Medicine. He is Director of Education at The Dartmouth Institute for Health Policy & Clinical Practice.


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