OverCompetitive Medical Students

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Introduction
Most medical students are well accustomed to competition. During bedside teaching, it's almost inevitable that one keen student will blurt out the answers to questions directed at others. But what happens when friendly competition turns nasty?

"Gunners"

With far fewer residency places than eligible graduates, medical students in the US are accustomed to competition. There, pathologically competitive medical students are referred to as "gunners."

"As a medical student, you will almost certainly encounter a gunner classmate at some point," says Sara Cohen, a rehabilitation physician in Massachusetts. "Some people use the term to refer to students who study much more than average and are especially concerned with grades. The term can also be used to refer to medical students who exhibit behaviour that is either borderline unethical or even blatant cheating."

Typical gunner behaviours, she says, include hoarding study materials, ripping key pages out of library books, dominating tutorials, and making comments in front of tutors that are meant to make the gunner look smarter than their peers.

"Unfortunately, gunner behaviour often escalates during the clinical years because grades are largely based on evaluations from the doctors observing you. A gunner may try to be the first person at work every day and the last to leave. He or she may try to leap in and do every available procedure or surgery, even on a patient who belongs to another student."

Sound familiar? A recent unpublished survey of students at a London teaching hospital found British medical students to be just as competitive as their US counterparts. Students reported stealing other people's memory sticks just before presentations, not informing peers about teaching sessions, and advising staff falsely that other students had behaved inappropriately on wards, or had not contributed to coursework. Furthermore, some medical students claimed they would be willing to mislead other students about exam content if they had the chance.

"Last year a friend of mine told me that an OSCE [Objective structured clinical education] I was about to take was really hard," says a fourth year medical student at St George's, University of London, who did not want to be named. "We had been studying together for some time, and he told me that nothing we had revised would come up. I became terrified and went into that exam sweating and shaking. But it turned out he was lying—it was a very straightforward series of stations that we were both well prepared for. I am quite sure he deliberately tried to scare me so that I would perform badly compared to him. The sad truth is that I might have done the same had I taken the OSCE before him. I don't think there's anyone you can trust at medical school when it comes to exams. Even your best friend might be willing to lead you astray."

Obsessive Personalities

What leads some medical students to such extreme measures? "Competitive behaviour has a range of drivers," says Phillip Hodson, fellow of the British Association of Counsellors and Psychotherapists, "firstly the personality of the student, but equally important is the system they are working in, which includes their family background as well as medical schools themselves."

Some students, he says, have an obsessive personality that predisposes them to competitive behaviour. "These students have a narrow mindset that says that the most important thing in the world is to succeed. Their number one focus might be to get a certain exam grade, or to get a job at a certain hospital. Students from successful families may be particularly afraid of failure. The worst case scenario would be a student whose parents were both successful medical professors. That's an awful lot to live up to."

Working within a competitive environment is highly stressful, says Phillip, particularly for medical students who are desperate to succeed, but also for those affected by their peers' aggressive behaviour. "Stress isn't always a bad thing," he says. "Humans need a degree of stress in order to perform, but beyond a certain point it can impair function, and ultimately it causes burn out. All life needs balance. If all you do is study then you're not really going to have a life—and you're probably not going to be a great doctor."

As competition to get into medical school in the UK is high, medical students may be particularly prone to obsessing about their performance, particularly when placed in an environment full of other academically successful students. "Not wishing to blow my own trumpet, and those of my peers, but medical students are some of the brightest in the country," says Joshua Harvey, a third year medical student at Oxford University. "Personally I found it a hard transition to go from a school where I was not really challenged by my work or peers to a place where it seems everyone is smarter than me. I have noticed that I am now much more concerned how I have performed in relation to the class. Feeling like I have done my best is no longer enough."

The Hidden Curriculum

Medical schools themselves may fuel competition through the "hidden curriculum," a set of cultural and organisational influences that can affect medical students' attitudes and behaviour over time. Students exposed to the hidden curriculum come to accept hierarchy, which is often learnt through teaching involving humiliation. In one study of medical students' perceptions, half the participants reported that competition, not cooperation, was the defining characteristic of medicine, a view that was more common among clinical students. In addition, more than a third of students reported a desire to impress senior staff in the hope of gaining prestigious jobs after graduation.

Ross Kirkbride, a foundation year 1 doctor in Bristol, feels that his medical school prompted competitive behaviour among students by encouraging them to think about their future careers early on. "Unfortunately, my medical school banged on about how we should make our CV better, and how we had to think about our application to a specialist training programme from day one," he says. "The message was always: you need to demonstrate your ability to organise by arranging a charity rowing trip across the Atlantic; you need to scramble to do an audit on in-growing toenails otherwise your mate will get that job in London; and so on . . . "

Arguably, a competitive environment at medical school might drive up standards. A student who works hard to ensure they are in their medical school's top academic quartile may emerge with more knowledge to apply to patient care; encouraging students to publish academic articles may give them a taste of medical research that they would otherwise have overlooked. Such achievements are not to be sniffed at. But what are the harms of setting such goals? Besides being potentially detrimental to student mental health, competition within the medical profession can ultimately damage patient care. Studies have shown that medical students are willing to compromise patient care to seem better than their colleagues. Such compromises include falsifying patient notes—for instance, recording signs that have not been elicited.

"The culture of competitiveness says that we get the best candidates for the job, and therefore patients are in the best hands," says Ross, "But really? Do you want a surgeon whose key attribute, distinguishing them from their peers, is self-promotion? People who excel at competing may be worse doctors than those who neither idolise medicine nor are willing to do just about anything to get that job. "Me first" naturally implies "you second," which may not be ideal for a vocation that demands some level of altruism and sacrifice."

Abolishing Grades

Is it possible for the competitive atmosphere in medical schools to diminish, or will medical students and doctors always be competitive?

Changing the way that medical students are evaluated can have an impact on the pressure they feel to do well. "One thing American medical schools have done is to eliminate grades in the first two years, which means that you either pass or fail a class," says Dr Cohen, "But I suppose the worry with such a system is that it doesn't give credit to students who have worked harder."

In the UK, even if medical schools adopt a "pass or fail" approach, a student's UKFPO application is affected by their academic quartile, meaning that some students may not be happy to simply pass exams. Furthermore, the news that the Foundation Programme 2011-13 was oversubscribed is likely to cause anxiety in many medical students,[1] and increase the pressure to gain bonus points by getting published in an academic journal or winning national prizes.

Karin Purshouse, chair of the BMA Medical Students' Committee, says: "Obviously we are concerned that there is a chance of oversubscription to the foundation programme in future, but it's really important for medical students to remember the importance of professionalism, which includes their duties towards colleagues as well as patients. Students should focus on developing the skills they themselves need to become a good doctor, rather than simply being better than their colleagues."

"Medical schools are already concerned about the impact that intense competition can have," she added. "Clearly competition can affect mental health, and there have been tragic cases of medical students becoming very unwell through worrying that they are not as good as their peers."

Despite the General Medical Council's requirement for medical students to learn to respect their colleagues and make the care of the patient their first concern, it is likely that some medical students will occasionally overlook these duties in order to succeed. So what is the best way to cope with fellow students whose competitive behaviour gets out of hand? "The best thing you can do is try to ignore the gunner's behaviour and do the best job you can on your own patients," says Dr Cohen. "Keep in mind that all consultants were once medical students, and they're often able to recognise gunner behaviour. Although the gunner may impress some doctors, others will be turned off by attempts at showing off. You may be gratified to discover that your seniors dislike the gunner as much as you do."


Reference: Medscape.com