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. 2001 Feb 3;322(7281):296.

Cheating at medical school

PMCID: PMC1119534
BMJ. 2001 Feb 3;322(7281):296.

Anonymous letter should have been consigned to the bin

S A Spencer 1

Editor—I was disappointed to read Smith's editorial on cheating at medical school.1-1 Trial by media has become a sign of the times, but I had hoped that the professional journal of the medical profession would rise above such sensationalism. It is easy for us all to be filled with righteous indignation about the cheating of a student, but we do not know all the circumstances, and I hope that adherence to confidentiality means that we never will.

The appropriate authority dealt with the issue, and I believe that it is nobody else's business. What right has the media to question a judgment based on facts when they do not have all the facts at their disposal? In any event, I wonder about the motives of the student who exposed this lapse by one of his or her colleagues anonymously.

Of course doctors must have integrity, but it is wrong to assume that a person lacks integrity on the basis of one incident. After all, who can affirm that they have never once been dishonest in their entire career? Hopefully, we learn from our mistakes and aim to do better in the future.

Smith says that justice is not a private matter and calls for exposure. I think that exposure has little to do with justice and much more to do with selling newspapers. Public opinion is more influenced by the media slant or spin than the facts of the case. How often do tabloid newspapers treat us to full exposure of the life of person who has been accused of a crime well before any trial has taken place? Where is the justice in that? We are in serious danger of engendering a situation in which the fear of publicity is such that decisions made by responsible people will be expedient rather than just.

I think that the BMJ should have consigned this anonymous letter to the waste paper basket and not taken the opportunity to call into question the integrity of a future member of the medical profession. This editorial does little to support a beleaguered profession and could cause much more serious damage.

References

BMJ. 2001 Feb 3;322(7281):296.

Incident was dealt with appropriately

Belinda Brewer 1

Editor—I was disturbed by Smith's editorial on cheating at medical school.2-1 In the current climate of doctor bashing by the media and the recent vigilante attacks on supposed paedophiles and mob violence in the name of justice, I was disappointed that Smith thought that doctors should respond to this student's cheating in a way that would show other students and the public that justice had been done. Rather than undermine faith in our system of justice I think that we should be highlighting that this matter was dealt with appropriately.

Smith's editorial was based on information in an anonymous letter, whose writer must have led a protected life if this is the most ugly scene that he or she had witnessed. If this was such a significant event surely he or she could have signed the letter? I note that Smith confirmed the facts with the medical school concerned, but owing to confidentiality I am sure that he was not given all the details.

We all know how stressful medical final examinations can be, the culmination of five or six years of striving to be a doctor. Depression, anxiety, and stress often unhinge previously stable minds. The student in this case had been exemplary before this event. I agree that cheating destroys trust and the incident must be dealt with professionally and fairly, but must we respond to a lynch mob mentality in order that justice is seen to be done? I think that the medical school probably responded in a measured way. Rather than lose a valuably trained doctor we have gained a professional who has learnt a painful lesson.

References

BMJ. 2001 Feb 3;322(7281):296.

Public horsewhipping is not the answer

Emile Tan 1

Editor—I read with dismay the aspersions cast at one of my colleagues and my medical school by Smith in his editorial on cheating.3-1

This matter was indeed public knowledge within a very short time. The fact that it was not deliberately publicised does not, I believe, signify an intention to cover it up. Such disciplinary matters must be commonplace in any school and are dealt with in private with all the facts present—as they should be. Who ever heard of a disciplinary board that worked like “America's Funniest Home Videos,” inviting the public to “press a button now” to decide the outcome? Which medical school can say that it has never had to deal with cheating before?

University College London Medical School has an excellent reputation in the United Kingdom and abroad, and its exams are rigorous. Such a matter should not call into question the validity of its degrees or the integrity of its tutors. Surely name calling is not necessary? As to the call for debate? By all means, but please keep everything in perspective.

It is in itself unethical and unnecessary to wilfully scupper the career of a young doctor if there is any way to prevent it. The doctor in this case has not killed or poisoned anyone, unlike some of our ilk. She has cheated, a crime, and she should be punished. By all accounts, she was let off lightly, but what would a public horse whipping do? It would destroy her both emotionally and professionally. The public's appetite for blood would be sated, but at what price? How could we as human beings forgive ourselves if she were to sink into depression and harm herself—for that may be the only way to go. We would have closed off all her avenues before her career has begun. Justice involves punishment, but after punishment must come rehabilitation and reintegration into the fold.

The people who need to know about her transgression no doubt already know. They must now be responsible for guiding her in the difficult times she has brought on herself. If she is repentant and able to do so, she must get on with life and become a good doctor—one to be proud of.

References

BMJ. 2001 Feb 3;322(7281):296.

Cheating should be treated like medical error

Chris O'Loughlin 1

Editor—The responses to the theme issue on medical error were published a week after Smith's editorial about a final year student caught cheating at medical school.4-1,4-2

Is there not a parallel here? Should we not only be looking at the person who cheated but also be finding out why it happened and how it can be avoided? Should we not stop upholding the supposed integrity of the profession by proudly expelling the miscreant according to the name and shame culture the BMJ was so critical of?

References

  • 4-1.Smith R. Cheating at medical school. BMJ. 2000;321:398. doi: 10.1136/bmj.321.7258.398. . (12 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Correspondence. Reducing error, improving safety. BMJ. 2000;321:505–509. . (19-26 August.) [Google Scholar]
BMJ. 2001 Feb 3;322(7281):296.

Committee should be commended for showing compassion

William Westlake 1

Editor—I enjoyed reading Smith's editorial about the hapless finals cheat and anonymous whistleblower—but only in the way that I enjoy reading the tabloid newspapers on vicars being caught in flagrante delicto with one of their parishioners.5-1

I am surprised that someone caught cheating in an examination is allowed to pass, and this outcome was probably a bitter pill to swallow for the unfortunate students who failed their finals without the peroperative assistance of the Oxford Clinical Handbook. However, two possible interpretations of the editorial are that anyone caught cheating in an examination is not fit to practise as a doctor and that justice can be dispensed only if the perpetrator of any deceitful act is publicly exposed and humiliated.

I may be wrong in disagreeing with the first contention that anyone caught cheating in an examination is not fit to practise, but I believe that in a compassionate and supposedly Christian society public exposure and humiliation is utterly contemptible. The anonymous whistleblower would certainly not have written to the BMJ if the cheat had been summarily dismissed from medical school with no hope of ever reaping the benefits of five or six years' hard work (I assume that even cheats have to work hard to get through medical school). The whistleblower's spiteful desire to see the cheat receive her comeuppance would have been fulfilled. He or she did not have the courage to put a name to these demands for a harsher penalty, and we can only guess at the true motives behind them (jealousy of the prizes of which the cheat has been stripped?).

The cheat has cheated no one but herself. I would be most surprised if her foolish use of the Oxford Clinical Handbook will have had any significant effect on the outcome of her examination, which is clearly what the disciplinary committee thought. The committee decided to treat her with compassion, something that is sadly lacking in the unpleasant world in which today's doctors practise. I think that the committee should be commended for showing compassion and not made to feel that it has somehow aided and abetted a mythical decline in the moral standards of the medical profession.

References

BMJ. 2001 Feb 3;322(7281):296.

Examination committee's decision tarnishes reputations

J Vive 1

Editor—The BMJ was right in helping to expose the astonishing episode of unpunished cheating during a final examination at the Royal Free and University College London Medical School.6-1 If the student who cheated was passed by the examination committee because she had previously been an exemplary student (and now there will forever be doubt on the veracity of this description of her), then what is the point of the examination if exemplary students will be passed even if they have cheated? Perhaps robust continuous assessment of course work would be a better alternative for all candidates and could still identify students worthy of distinctions and prizes.

Exemplary students have failed for various mitigating reasons throughout the history of examinations. Many have swallowed the bitter pill and tried again, often with salutiferous effects. This is the first example I know of a cheat being passed when she should have failed. Not only was she dishonest (at least once) but she clearly had an illicit and unfair advantage over other candidates sitting the same examination. In undermining the whole process, the examination committee has failed all graduates of this medical school. A question mark must now hang over all graduate results from this medical school if confidence is lost with the examination committee, as now seems likely. If the cheat's identity remains anonymous, all recent female graduates from this particular school may be subconsciously or consciously viewed with suspicion at future job selections. This potential for discrimination is perhaps the greatest cause for concern among the honest female candidates who passed fairly.

The examination committee's extraordinary decision to pass a cheat needs an immediate full explanation (and perhaps an apology) if irreparable harm to the reputation of the Royal Free and University College London Medical School, its graduates, and the medical profession is to be minimised.

References

BMJ. 2001 Feb 3;322(7281):296.

Cheating should be properly punished

Neil Fergusson 1

Editor—Smith in his editorial asks whether the BMJ was right to publicise the episode of cheating during a final examination at the Royal Free and University College London Medical School.7-1 I am surprised that he felt the need to ask—of course it was right.

The editorial raises two issues. The first is whether the student had attained the required standard without resorting to cheating. The examining committee obviously considered that she had but without proof (how often had she cheated in the past?). Surely the public needs to have confidence that all doctors have shown beyond doubt that they have the knowledge and ability to practise safe medicine? This has not happened in this case. I wonder what would have happened had this been an A level examination.

The second issue is the naivety of the committee in thinking that the medical profession wishes to adhere to old fashioned paternalism and allow a student to pass because she is known to be a good student. It is for just this reason that the General Medical Council has lost the confidence of the public. What happens now that the standards of academic achievement of the entire medical profession are to be questioned?

Smith is correct in saying that justice not only has to be done but also must be seen to be done. I am deeply upset that the student was not asked to resit the entire examination at the next sitting. I am grateful that some members of the profession are prepared to state publicly that the judgments made in this case are simply not good enough for a modern profession.

References

BMJ. 2001 Feb 3;322(7281):296.

Keeping quiet about cheating will not increase public confidence

Rod MacQueen 1

Editor—Smith's editorial on cheating makes me more positive about the medical profession's future.8-1 We as doctors are not practising a secret craft any longer, and more openness and public discussion, although causing its own problems, is far to be preferred to mutterings about the secrets of our craft. After the Bristol affair, the Shipman case, and many others—particularly after evidence that responsible bodies ignored warnings and advice—keeping too quiet will not increase public confidence. The public will begin to ask what other skeletons are hidden in our cupboard.

References

BMJ. 2001 Feb 3;322(7281):296.

Public declaration of an appropriate punishment is important

Michael Jarmulowicz 1

Editor—I support the BMJ's publication of the details of a student's cheating in her final examinations.9-1

Although professional knowledge and skills, which can be tested, are an important component of a doctor's work, I believe that the most important qualities in a doctor are honesty and integrity. Patients must be able to trust their doctors. In my experience, most patients will accept and understand when mistakes are honestly and openly explained.

When medical errors are publicised an important aspect of the criticism is the actual or perceived cover-up of the facts. Society is losing its trust in the integrity of the medical profession, and this is just as damaging as poor performance.

Although I have no personal knowledge of this case, I believe that the minimum appropriate punishment should have been to resit the examination. Important aspects of publicly declaring an appropriate punishment are to act as a deterrent to others; to highlight the importance of personal integrity; and to promote a culture of intolerance to dishonesty in the medical profession.

References

BMJ. 2001 Feb 3;322(7281):296.

Main impact of cheating is on clinical work

James Paton 1

Editor—Smith asks whether the BMJ has done the right thing to publicise an episode of cheating at medical school.10-1 Absolutely, and well done.

Early last year our department secretary told me that she thought that one of the final year undergraduates in our child health block had forged a consultant's signature to confirm completion of a compulsory component of the course. The forgery was crude and easy to detect; the student was confronted and admitted to doing it. The student failed the block as a direct consequence and will have to complete, satisfactorily, further “retraining” before proceeding to finals. It was made very clear that a similar action after qualification would be likely to result in referral to the General Medical Council.

Perhaps this student was just unlucky to have been caught: others had probably cheated before but not been discovered. However, at least we made a public response saying that we regarded it as cheating and unacceptable. All a bit depressing in a university medical school which widely and publicly states, throughout campus and on its website, that its first core value is the “habit of truth.”

Smith rightly highlights the erosion and destruction of trust that follows cheating at medical school, but the main impact is not on the academic process or research but on daily clinical work. It would be almost impossible to function in a clinical team if you could not believe your other team members implicitly (“Have you really completed the consent form—or did you just forge it?"). And if you lie and cheat as a student, it is not likely to stop when you come up against the rigours of daily clinical practice. Just imagine, too, what might happen to the doctor in our bright new future who is caught forging his continuing professional development log in the GMC revalidation process.

Interestingly, the student in our department, like the one whose case was described by Smith,10-1 was another good student and was in line for a merit certificate. Perhaps all good students are cheats and liars.

References

BMJ. 2001 Feb 3;322(7281):296.

Are we all cheats?

Phillip Bennett-Richards 1

Editor—It was manifestly wrong for the medical student to take the Oxford handbook into the examination.11-1 It is clearly wrong to seek to gain unfair advantage in an examination, whose rules and regulations are laid out. I would, however, be interested to know whether the former medical students who have been fulsome in their condemnation of this individual on bmj.com11-2 can claim to have never seen a multiple choice question from a past paper, received some hot tip for the written paper, or sought some knowledge of the cases in the clinical examinations from those who have just completed their assessments.

I feel confident in being able to guarantee that every medical school graduate in the past 20 years has transgressed in one of these ways, either as a student or as a doctor preparing for postgraduate examinations.

The board of examiners had to exercise wisdom. Their decision, as is to be expected, has not pleased everyone but was their prerogative. It was also Richard Smith's prerogative to air the issue in public. Is it too much to hope that the circumstances of this case can be used to move towards a more equitable examination system rather than the witch hunt that it seems to have become?

Are we all cheats?

References

BMJ. 2001 Feb 3;322(7281):296.

Cheating also happens on the large scale

Editor—As recent graduates from medical school, we would like to describe a recent case of cheating on a much larger scale than that described by Smith.12-1

Less than 12 hours before our first clinical examination we received a telephone call from a fellow finalist claiming to have a full list of the stations making up the objective structure clinical examination. Two students had seen the mark sheets when making inquiries at the examination office two days previously and had decided to disseminate the information.

What to do with the information proved to be difficult. Our consciences did not rest easy. Undoubtedly some candidates would have known the content of the examination for over two days and were confident of their sources' reliability. What also bothered us, however, was that many students would not have received a telephone call at all.

The details we had received proved accurate. From conversations after the examination we learnt that many students had selectively revised and practised the subjects which they knew would be examined from the details they had received two days before (and the last 48 hours' work do make a difference).

Around half of the year was awarded a merit or distinction, awards that are given only to students gaining a merit in one of the two clinical examinations: the objective structure clinical examination and the long case. The number of merits and distinctions awarded this year was noticeably higher than in recent years.

As a result of this cheating many very able candidates who passed finals honestly will now seem to be less able on paper than some less able students who received the information. Undoubtedly, many less than average students had surprisingly good results after gaining merits in their objective structure clinical examination. Some students may have passed who would have failed had they not been privy to the examination details.

Will these dishonest people now be favoured for the best senior house officer jobs because they have good finals results? And will other equally if not more able students who were not informed of the examination details be penalised as a consequence? These are unanswerable questions.

Our consciences still struggle with this. We hope that the other 100 or so students involved also feel uncomfortable.

Cheating clearly happens at all levels and on all scales. We were all in the wrong, and perhaps we should have dealt with the problem differently. Should we now admit who we are and have our merits and distinctions and even honours awards taken away?

References

BMJ. 2001 Feb 3;322(7281):296.

Summary of rapid responses

Sharon Davies 1

This editorial touched a nerve: responses came thick and fast. We posted 101 responses by 95 different respondents (or groups of respondents) from 10 August to 22 November, a fifth of them (21) on 15 August alone.13-1 Two thirds of responses (66) were posted during the first week of the editorial's availability on the web and nearly three quarters (74) during its first week of publication in the printed journal. We also received nine other letters by post.

Only four of the 85 respondents who gave their position were not medically qualified or in training. Forty four were specialists, 10 general practitioners, nine doctors working in academic institutions, seven medical students, six junior doctors, and three “doctors” or “medical practitioners,” while two were retired. Most respondents (60) came from the United Kingdom, but seven were from Australia, six from the United States and Canada, three each from the Republic of Ireland, Europe, and India, two each from Hong Kong and South America, and one each from Malaysia, South Africa, and Japan.

Most respondents agreed that the editorial should have been published and thought that it raised important issues. The repercussions of cheating for the student and her peer group and on the medical profession as a whole were hotly debated, as well as the appropriateness of the punishment in this particular case. An important thread of the debate was whether the examination system should be changed to assess better the skills required of doctors in an age of information overload and increased patient awareness.

One of the most interesting threads, however, was the scale and extent of cheating at medical school. Five respondents asked to remain anonymous to blow the whistle on instances they had encountered. Nor is cheating new as this quote from the Daily Herald of 21 March 1938 shows: Wholesale cheating has caused abandonment of a medical students' examination in London. The students, 150 of them, were taking a physiology paper set by the Conjoint Board. That cheating was going on was discovered only 15 minutes from the end of the examination. The supervising examiner grew suspicious when 20 students, one after another, asked permission to go to the cloakroom. Mr Horace New, secretary of the Conjoint Board, was asked to investigate. Behind a pipe in the cloakroom he found a “cram” book.

Might cheating at medical school remain endemic unless it is tackled openly?

References

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

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