#7 Moral (or Morale?) development in medical trainees

Host: Jonathan Sherbino

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Episode article

Liu, L. X., Goldszmidt, M., Calvert, S., Burm, S., Torti, J., Cristancho, S., & Sukhera, J. (2022). From distress to detachment: Exploring how providing care for stigmatized patients influences the moral development of medical trainees. Advances in Health Sciences Education, 27(4), 1003–1019. https://doi.org/10.1007/s10459-022-10125-7

Learning is social.  Caring for stigmatized patients can have a negative impact on trainees.  In this episode we discover how frustration and futility during patient care may lead to future apathy and moral detachment as a physician.


Moral choices – what is right, what is wrong – yeesh. It’s an age old question, one Socrates posed “How should we live?”  In this post-modern age I get anxious quickly, trying to imagine how to steer our conversation.  On-line forums are filled with social justice warriors.  Cancel culture moves quickly with a hive mind.  I am proud of this current generation, my children, actively seeking to undo oppression, injustice, hierarchy and more.  But I also worry about third-hand interpretations of motive and position that accompany public conversations about “moral choices.” 

Enter Liu et al. (and friends of the show Mark Goldschmidt, Sayra Christancho, Javeed Sukhera) who invite us to confront morality in medicine.

Recognizing the need for thoughtful, patient, and authentic approaches,  why don’t we set the stage a bit.  Jason, Linda, Lara, should HPE even be discussing with morality?  How was this theme explicitly addressed in your professional training? Can we imagine common moral principles expected of all health professionals or is the phenomenon a personal one?


The authors set out to “explore how working with a stigmatized patient population such as PWID may influence the moral development of medical trainees.”


This work is informed by sensitizing theories and frameworks that include such concepts as:

  • Both cognition and affect (e.g., empathy) interdependently influence moral decision-making;
  • Socialization helps to internalize morals;
  • Learning is a transformative process via cognitive, affective, and experiential processes, including formal teaching, role modelling, informal conversation, and implicit/explicit expectations; and
  • Empathy (understanding rather than feeling the perspective of another person) can be impeded when negative arousal overwhelms an individual triggering self-focused behaviour (frustration, avoidance, numbing), rather than compassionate actions, to relieve distress.

A practice-based approach (drawing on CGT) and informed by sociomateriality was adopted.

Data included 150 hours of direct observation (rounds, handover, bedside interactions) of 48 participants from two acute-care hospital medical wards, and 157 minutes of field interviews and follow-up interviews. Participants were medical students, family medicine residents or internal medicine residents caring for patients who inject drugs. Clinical documentation (admission notes, discharge reports and daily progress notes) was also reviewed.

Concurrent, iterative data analysis (congruent with CGT) was conducted until theoretical sufficiency was achieved.


Cyclical care of PWID triggers frustration and a sense of futility in trainees, distinct from other populations.  This frustration perpetuates a sense of futility that leads to adaptive behaviours that negatively impact their pare of patients, such as emotional distancing and physical avoidance.

A lack of trust and rapport between trainees and PWID impacted care. Finding common ground, establishing shared goals, and ongoing distrust by patients impaired the therapeutic relationship.

Supervising physicians or senior residents role modelled communication and relational styles that were neither relational nor trauma informed.

Heavy patient loads and bed pressures disproportionately impacted care for PWID. Follow-up care was difficult to facilitate.

Electronic documentation perpetuated stigmatizing labels of PWID.


The authors conclude:

Fostering empathy through moral development … has become … as important as … acquiring bioscientific acumen. Yet, despite the best efforts of medical curricula to teach communication and empathy, trainees continue to struggle with apathy, moral distress and moral detachment, particularly when caring for marginalized patients with complex psychosocial needs. Our findings suggest that negative role-modelling alone cannot fully explain why trainees continue to struggle with empathy…. For stigmatized populations like PWID, we need to reframe the way in which we define successful care and to be mindful of the structural and institutional forces which are at play.”

To return to the title, the morale of trainees seems to correlate with the moral decision-making they employ. One last thing. The lead author is a medical student.  Shout out to Lisa Liu! you’re going to go far in HPE research!

The Last Word –

Comments from the author, Robert Sternszus MDCM,MA (Ed), FRCPC

Hi Linda. Thanks for the heads up on the podcast. I’m truly thrilled that it is being discussed and that really was the whole point (the stated intention of the paper was ‘to start a conversation.’) In case anyone was concerned, I was in no way offended by the critique although I disagreed with much of it.

In particular, the premise of the entire critique implies that the paper was interpreted in a completely opposite way to which I felt it was written. And that, in and of itself , is interesting and important in terms of how we talk about these concepts moving forward.

The ‘blurb for the podcast’ sets it up with: ‘Is a competency-based approach to health professions education compatible with professional identity formation? These authors say no and offer some remedies.’

And yet, the closing sentence of the introduction/purpose statement of the paper explicitly states the opposite:

‘In this paper, we argue that CBME and PIF are not only compatible, they can also both be enhanced by reconciling one with the other.’

The argument line was intended to reflect that the ways in which PIF and CBME have both been described and operationalized, which are sometimes actually at odds with their theoretical underpinnings (as the group highlighted), have made them seem incompatible to many when they in fact are not. The importance of identifying and naming the perceived contradictions lies in being able to debunk them and point to opportunities and solutions Which, I agree with Jason and Linda, is the value of the paper. Ultimately, initiatives explicitly intended to help support reflection and engagement with PIF have not been meaningfully incorporated into many curricula in part because curriculum designers struggle to see how to do that in a curriculum that is entirely centered on EPAs and competencies.

Lastly, I think the discussion around assessment is an important one. Professional identity and professional identity formation are NOT competencies (agree fully!) And, also agree fully that one’s professional identity should not be assessed. However, I think formative guided self-assessment of the process of forming a professional identity can be a powerful trigger for reflection. And, given that CBME implementation has often meant exclusion/minimization of things that cannot be ‘assessed’ (again, not what CBME theory says but what plays out in practice) conceptualizing assessment around the process of PIF is a launch point to help curriculum designers include it meaningfully.

All of that said, it’s been really fun to see the chatter the paper has generated (it was selected as a MedEd must read for February in addition to being in the podcast). And I am grateful for the time and thought that was put in by the Papers Podcast team in reviewing it.

A demain



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