Residency Interviews: The Ethics of Asking Ethical Questions

A professional interview is an opportunity to identify qualified applicants who meet a variety of requirements. It provides insight into an applicant's character, judgment, experience, and suitability for a field or institution. When matching physicians to residency programs,¹ the Association of American Medical Colleges recognizes that “knowledge of professional behaviors and interpersonal and communication skills” is “less easily assessed in traditional application formats.”² In addition, “applicants who fall in the middle (ie, may not have the highest board scores but may excel in other areas) may be overlooked.”² A face-to-face interview provides an experience that cannot be replicated, by offering insights that will substantially enhance the decision-making process.

The interview provides the opportunity to assess applicants' ethical sensibilities, which underpin the core attributes of a well-trained physician—professionalism and humanism.³ The American Medical Association's Principles of Medical Ethics delineates “standards of conduct that define the essentials of honorable behavior for the physician.”⁴ The importance of personal and professional ethics in a physician has been emphasized across medical specialties as well. According to the American Board of Internal Medicine Foundation Physician Charter, a physician must maintain “standards of competence and integrity” to maintain public trust when providing “expert advice to society on matters of health.”⁵ The 3 fundamental principles of medical professionalism from the American Board of Internal Medicine (primacy of patient welfare, patient autonomy, and social justice) are, in essence, the beneficence, autonomy, and justice components of principle-based ethics. Physicians who interview resident candidates have a responsibility to maintain these principles by selecting applicants who aspire to, and can eventually attain, those standards.

How can the residency interview be used to learn about candidates' ethics and assess their potential for ethical growth? We present a few types of questions to deconstruct the different methods of interviewing, and we posit that some questions about ethics are ethical but do not explore relevant issues, some are unethical, and some are both ethical and potentially illuminating.

Ethical Questions That Are Not Useful

The first type is a question of fact, such as asking a candidate to discuss Socratic irony or to define deontology or utilitarianism. While knowledge should be a focus of some attention, the interviewer could glean a greater understanding of a candidate's mastery of that competency from a medical school transcript or US Medical Licensing Examination score than from a few random questions posed at an interview. The goal is to learn more about who applicants are, not what they know. These types of questions might be ethical to ask but would not provide insight into the candidate's proclivity for ethical reasoning.

Unethical Questions

The second type are those that interviewers may use as ethical questions, but are ethically suspect when used in this type of interview. Questions such as, “Are you ‘pro-life' or ‘pro-choice'?” may help interviewers assess a candidate's moral comfort zone, but they do not reveal what is really being sought. Two “pro-life” candidates may differ widely on how they reconcile their moral worldview with how they would counsel a woman carrying an anencephalic fetus who asks about her options. A well-versed applicant might be able to articulate that one's personal moral code does not equate to his or her professional ethical behavior. Ethics involves taking morality and fitting it into a social construct—family, culture, or a profession. Most concerning would be the predilection to grade applicants based on how closely their moral code lines up with an interviewer's personal beliefs or political agenda, and that approach is inappropriate, if not unethical.

Ethical and Potentially Illuminating Questions

What kinds of questions would be both ethical to ask and useful to explore? Each medical specialty could identify commonly occurring scenarios that may trigger ethical distress. The goal should be to have the candidate work through moral dilemmas with a focus on the ethics process and how the candidate evolves an ethic from a morality. For example, asking a candidate how to allocate intensive care unit beds or respirators during an influenza outbreak by describing the patient's age, race, ethnicity, or underlying comorbidities could uncover sensitivity to social determinants of health and quality-of-life considerations.⁶ Asking how applicants would react to a patient who wanted her husband to choose the contraceptive method she will use, or one who wanted the advice of a religious leader before accepting a recommended course of care, could elicit ethical principles, such as respect for cultures whose priorities may not match those of the applicant.

It is acceptable for candidates to struggle with these issues, but they should be able to articulate the points of discomfort and consider a path forward that is respectful to patients and their beliefs, even in circumstances where they feel they cannot ultimately acquiesce to a patient's requests. They should be able to create or be cognizant of rules that guide and underpin choices and show consistency and integrity as they deliberate these situations.

Assessing Ethical Questions

Ethics is not merely a short-answer quiz with right or wrong answers. Allowing candidates to think aloud in a safe space where they can reflect on the principles invoked can facilitate a conversation that reveals the sophistication and sympathies of the candidate. The way in which a candidate's ethics and professionalism are assessed will be just as important as the interview itself. Training interviewers in techniques such as behavioral and situational interviewing, based on the premise that past behavior or intentions predict future behavior,⁷ is one process that structures the questions and the rating of response.⁸ Asking applicants to describe a specific situation, the actions they took, and the outcome of the event can provide insight into the ethical domain.⁷

Summary

Interviews are opportunities to find individuals who will be a good fit, allowing residency programs to look beyond a candidate's intellectual capability and training. The program can assess other qualities, such as behavior, manners, and conversational abilities, at the interview itself. The fervor with which a candidate embraces these questions, in and of itself, contributes to the assessment of the candidate's suitability for a medical specialty.