Do what I say, not what I do

Scienti®c fraud is a serious matter and

those who commit it are culpable. When

the fraud in question involves a clinical

study or has a direct bearing on patient

management, the matter may be

regarded as especially reprehensible.

Such deceit may lead to patients

receiving inappropriate or dangerous

therapy on the basis of the published

results. At the very least, time and

resources may be wasted in trying to

replicate the fraudulent results. The

extent of the problem is uncertain

but the GMC has recently struck off

a surgeon for a fraud committed

10 years previously. One of the worrying

aspects of the case was the revelation that

the surgeon's research supervisor and

other senior members of his university

were aware of the fraud and did not take

any action during the 10 years. The

research supervisor himself has since

been found guilty of professional mis-

conduct for his failure to take action.1

Against this background, it is dis-

turbing to ®nd that a substantial

majority of medical students would not

report a colleague they knew to be guilty

of academic misconduct.2 The reasons

adduced for this attitude are varied and

re¯ect the ambivalent approach to aca-

demic misconduct demonstrated in the

responses3 to Smith's editorial4 on a

student who was found to have cheated

in the Finals examinations. Many of the

explanations given appear to be

rationalisations for the widely held

disapproval of `informers' within British

culture and may re¯ect a feeling that

academic misconduct is not a terribly

serious affair. However, there does not

seem to be any difference in kind

between cheating in an assessment and

falsifying the results of a research study

in order to get it published. Both are an

attempt to gain academic advantage by

dishonest means. It is dif®cult to dis-

agree with Glick when he says, `It is

reasonable to assume that cheaters in

medical school will be more likely than

others to continue to act dishonestly

with patients, colleagues, insurers, and

government.'5

To be `honest and trustworthy' is

one of the Duties of a Doctor, as

de®ned by the General Medical Coun-

cil, as is the duty to `act quickly to

protect patients from risk if you have

good reason to believe that you or a

colleague may not be ®t to practise'.6

The medical students in Rennie and

Crosby's study gave assent to the latter,

stating that they would blow the whistle

if they thought a patient was at risk. If

this narrowly utilitarian approach is

taken, there must be a reliable means of

identifying that a patient is being put at

risk. This may be straightforward in the

case of immediate risk, but may be

much more dif®cult in the case of risk

at a later date. A settled habit of

dishonesty and untrustworthiness may

well put future patients at risk and it is

at least plausible that the student who

passes assessments by cheating may not

have acquired the knowledge and skills

needed for safe practise. On either

argument the student will become a

practitioner who is `not ®t to practise'.

A profession is de®ned by, among

other things, self-regulation. The

concept of self-regulation implies a

shared ethos and agreed standards of

behaviour. It also requires effective

sanctions against those who depart

from the agreed standards. The med-

ical profession within the UK has, at

®rst sight, all of these components.

The shared ethos is de®ned in updated

versions of the Hippocratic Oath such

as the Declaration of Geneva and

codi®ed as agreed standards of beha-

viour in publications from the General

Medical Council such as Good Medical

Practice. Sanctions for those who fail

to meet the accepted standards in-

clude suspension or erasure from the

Medical Register with consequent

exclusion from the right to practise.

Recent high pro®le cases have,

however, strengthened a widespread

perception in the media and among the

general public that self-regulation has

failed. Following the Bristol paediatric

cardiac surgery investigation, there has

been a succession of cases where doctors

known to be incompetent have appar-

ently been allowed to continue in prac-

tice unchecked for a considerable period

of time. This is partly a systems failure in

that the methods for identifying poor

performance are not well developed but

it is also due to reluctance on the part of

colleagues to report their concerns about

individuals. Clinical audit has been

widely introduced, but it is often

dependent on inadequate data collection

and processing systems. A major failing

in the past has been the lack of mana-

gerial surveillance of the audit system.

This has been addressed in the new

emphasis on Clinical Governance within

the National Health Service7 but this will

only be fully effective in so far as the

maintenance of standards within the

profession is perceived as the responsi-

bility of every individual. When loyalty to

an individual colleague takes the place of

loyalty to the professional ethos faults go

unchecked and major harm is done to

patients and to the colleague one is

seeking to protect.

Rennie and Crosby report a percep-

tion among students that the medical

school should be responsible for

detecting cheating thus freeing the stu-

dents from the need to blow the whistle.

If this repudiation of responsibility con-

tinues after they graduate Clinical

Governance will not produce the hoped

for improvement in standards of patient

care. The challenge for medical educa-

tors is to inculcate professional stand-

ards so effectively that whistle blowing is

unnecessary but to ensure that it will

occur if needed. This may need a

fundamental shift in our approaches to

Commentaries

Correspondence: Sam Leinster, Dean,

School of Medicine, Health Policy and

Practice, University of East Anglia, Norwich,

NR4 7TJ, UK. Tel.: 01603 593939; Fax:

01603 593752; E-mail: s.leinster@uea.ac.uk

Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:113±114 113

the assessment of medical students8 and

in our own attitudes to professional

behaviour.9 Perhaps the real problem is

that the students in Rennie and Crosby's

study are re¯ecting what we do rather

than what we say.

Sam Leinster

Norwich, UK

References1 Ramsay S. UK consultant censured for

failure to act on junior's research fraud.

Lancet 2001;357:780.

2 Rennie SC, Crosby JR. Students'

perceptions of whistle blowing: implica-

tions for self-regulation. A question-

naire and focus group survey. Med Educ

2002;36:173±9.

3 Letters. Cheating at medical school.

BMJ 2001;322:296.

4 Smith R. Cheating at medical school.

BMJ 2000;321:398.

5 Glick S. Cheating at medical school.

BMJ 2001;322:250±1.

6 General Medical Council. Good Medical

Practice. London: General Medical

Council; 1998.

7 Clinical Governance. Quality in the new

NHS. http://www.doh.gov.uk/clinical-

goverance/hsc065.pdf.

8 Ginsburg S, Regehr G, Hatala R,

McNaughton N, Frohna A, Hodges B,

Lingard L, Stern D. Context, Con¯ict

and Resolution: a new conceptual fra-

mework for evaluating professionalism.

Acad Med 2000;75 (Suppl.):S6±S11.

9 Satterwhite RC, Satterwhite WM III,

Enarson C. An ethical paradox: the ef-

fective of unethical conduct on medical

students' values. J Med Ethics

2000;26:462±5.

Do what I say, not what I do · S Leinster114

Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:113±114