Should medical schools find a way to fail gunners?

In the satirical novel The House of God, author Samuel Shem writes about experiences as a medical student at Harvard.  In the novel, many famous quotations are used that have been passed on from generation after generation of medical students and residents.  Some slang terminology is also referenced and characters are created to illustrate the qualities of certain types of students.

One particular student that is found in every medical school class is the gunner.”  The gunner is a term used to describe a hyper-competitive medical student who is motivated by performance and grades and will stop at nothing to succeed. Almost every medical school class in the US has a couple of students with this character trait.  All of us who have trained in the past can still remember who these students were in our own classes.  Sadly, a gunner feels no remorse about climbing over others to achieve success on the medical wards when being evaluated by attending physicians.  A gunner never learns how to work well with others and, although performs remarkably well on exams and evaluations, is often left without essential skills for success in medical practice.

In the New York Times, Pauline Chen writes about the inability of the current medical education system to “fail” students with poor interpersonal skills and the inability to work with a team.  Now, more than ever, teamwork in medicine is essential to success.  In the article the story of a bright, young medical student is detailed.  This young student is able to ace all of the written exams but isolates herself from classmates, treats nurses and colleagues with disrespect and is unable to accept constructive criticism.  The attending physician supervising the student laments that he is unable to “fail” her due to the fact that there are no objective evaluations in the medical school grading system to deal with important attributes such as bedside manner, communication skills and interaction with nurses and colleagues.

In my opinion, this story illustrates a major flaw in our medical education system.  We have a responsibility to students as well as future patients to help create doctors who are not only brilliant diagnosticians and clinicians but are also compassionate, caring and able to easily work with others.  No longer is medicine practiced by the physician in isolation.  Today, medicine is centered around a team approach.  Nurses, physician extenders, social workers and physicians all work in concert to produce excellent patient outcomes.  Healthcare reform has now mandated certain (sometimes arbitrary) quality measures and it is only through a comprehensive team approach that these can be achieved and (more importantly for the government) documented.  Nothing productive has ever emerged from a negative confrontation with nurses or colleagues in a hospital.  We must reward students who display the ability to work well with others and effectively communicate with staff.  More importantly, we must teach students how to readily accept and respond to constructive criticism and continually self evaluate.

Certainly, proficiency with test taking and knowledge acquisition is essential to creating a successful, effective physician.  However, a physician who is able to work well with teams and communicate effectively with non physician support personnel is just as essential. We must develop a system put that actively strives to teach and evaluate these important interpersonal skills in medical school.  Once students are advanced to internship and residency, these bad habits are much more difficult (if not impossible) to break.

Competitiveness and striving for excellence are still important qualities in medical students.  However, compassion and concern for others may be even more rewarding in the long run.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • John C. Key MD

    I don’t understand why some of my favorite bloggers are electrophysiologists. Surely they were gunners themselves.

    The gunners I knew (I was not one) became excellent physicians and left their “‘gunner” days behind, it having been merely their survival mode for medical school and training.

    The currently most-vaunted “team” concept will likely collapse under its own weight eventually but the strong individual–the cardiologist, the surgeon, the intensivist–will survive to remain at the top of the pile through their personal quest for excellence.

    Trying to adopt a model to select out those with the best herd mentality is not likely to produce a good result.

    • Paul Dorio

      You hit the nail on the head so eloquently I can’t begin to “like” it enough. Thanks.

      I would also add that the author clearly is on the other side of appreciating the value of competition. Our children are being taught that “we all are winners.” How can you possibly know what it is like to win if you never have lost? And as far as the “gunner” is concerned, can you imagine if the system were to fail each of these hard-working, aggressive students? Fostering teamwork and compassion is important, agreed. But attempting to eliminate any other type of personality is short-sighted and ill-advised.

      • John C. Key MD

        Thanks its good to know I’m not alone on an ice floe,

        • Paul Dorio

          It’s not like I liked the gunners in my class back then. But they definitely made me want to step up my game. Thankfully, like you said, most of them matured beyond their negative gunning habits and into aggressive hard-working productive individuals.

    • buzzkillersmith

      Dr. K hit the nail on the head. The current teamwork fetish is a flash in the pan. I say this as a family. In time society will rediscover that our stock in trade is diagnosis and treatment.

      And the NYT doc was autistic, not really a gunner. She will likely not do well.

      Medicine has no place for sociopaths, those who cheat and lie and such. I’ve met a few. One is in rehab for the nth time after crashing his care while on Fentanyl. Drug addiction should be treated but this guy is way past that.

      But there are smart jerks in medicine. I agree also with the poster who stated that most mellow after being slapped around a bit by life. A good thing.

  • C.L.J. Murphy

    If there were one profession where “tall poppies” should be allowed to flourish and not be cut down for the sake of appeasing the rest of the field, I should have thought it would have been medicine.

    • Charles Knouse

      I agree with Murphy. The last thing we need is (are?) more cattle in medicine; this idea that a good medical student should “go along to get along” is precisely what’s wrong with our current system that is essentially an apprenticeship not entirely different from the guilds of the middle ages. The guilds held back progress in order to maintain their current profitability, thus denying society the benefits of innovation as well as the benefits of lower costs of production resulting in lower costs to the consumer. We have the same problem in medicine: simple, cheap and effective treatments are ignored in favor of pricey fancy specialist treatments that don’t actually work very well – but medicine will faithfully circle the wagons to protect bad medicine in order to maintain profits; “tall poppies” who try to do something about this get their heads chopped off in short order.

  • John Henry

    No, medical schools should not be looking for ways to “fail” anyone. That grim duty I would hope to be exercised sparingly and only in cases where no other remedy is suited. Competitiveness might be irksome to those who would like to take things easy in medical school without being seen as uncompetitive or feeling left behind, but life requires more, even after being selected by the admissions committee.

    You appear to be conflating the students who realize they must work hard to reach the top of their class and are willing to put forth more effort where they think it will matter with those who do dishonest and unethical things to do well. I think of the “gunners” as being the first group. The second group are people with antisocial traits or worse. The first group raises the bar for everyone, and that is a good thing, and no, I don’t think those people should be singled out for being failed.

    I troubles me to see faculty of medical schools adopting the hive/herd mentality, thinking it is their duty to produce docile, easily led “team” members. (And dishonestly implying that that is the only way to produce “caring” physicians.) I am grateful that kind of thinking was not popular when I went to medical school.

    • buzzkillersmith

      When you join the team you might find yourself under the senior midlevel, with him or her under the junior administrator. Only a fool would go through 4 years of med school and a minimum of 3 years of residency to end up in that predicament.

      • Lori

        then why do drs join foundations to become employees of administrators that don’t have half the education or risk when it comes to patient care? I am a nurse of thirty years and I find it appalling that physicians have thrown in the towel and allow themselves to be herded after working so hard. I have worked collaboratively with excellent physicians; the old school does not want to be an employee. The younger docs want to go home at 5.

  • Robert Goodhope

    gunners are a blessing, some go on to be Harvard and Johns Hopkins Professors and Chairs, which allows the us to say “I knew them when . . “

    • PoliticallyIncorrectMD

      And this suppose to be a good thing? To me it speaks to having a culture of unhealthy competitiveness in some major academic institutions.

  • Daniel

    Anyone else disturbed by the level of compassion demonstrated by the attending who “laments that he is unable to ‘fail’” a student for showing an insufficient level of compassion? Perhaps we need more role models who are able to show students what real compassion looks like.

  • SaraJMD

    I don’t understand why the obsession with “failing” such students, as opposed to helping, remediating, or better yet, creating a culture that fosters teamwork a lot more than our current system of medical education does. I’m not sure what failing med students actually does for the world. The NYT piece does detail a fairly extreme case, likely a student with a psych diagnosis of some kind who really needs help, not a black mark on her permanent record. The problem isn’t not that teamwork and effective communication cannot be learned, but that our system of medical education isn’t teaching these skills, and as the NYT piece points out, doesn’t know HOW to teach them.

    • Joe’09

      Some people shouldn’t be doctors, but are able to fake the smiles and handshaking well enough to get through the admissions door. They should be sorted out and encouraged into areas of medicine where they won’t harm patients, test scores notwithstanding.

      • Charles Knouse

        If there is one lesson of history and economics medicine should pay attention to, it’s that no economic system in the history of the world has succeeded in providing for humans…irrational humans of varying levels of cognitive and emotional intelligence…better (or even equal to) a true free market: true capitalism.
        I know this will raise howls of protest and vituperative indignation, but the simple fact – to me and, I believe, other students of the factual history of humanity – is that medicine is no longer even remotely a free market. Thus, the cry against competitiveness. Because medicine is not a free market system, it will inevitably continue to decline – until this problem is fixed – as herd mentality takes over, driven at the top by power-freaks who love to control, and driven from the bottom by weak “cattle” who want to be controlled. Any profession that abandons competitiveness is in opposition to the realities of human nature, and will destroy itself, fragmenting into tribes that fight against each other, continue superstitious practices, and stifle competitive advancement.

  • Steven Reznick

    Overly ambitious and overly compulsive and competitive are pretty good characteristics for someone in a demanding profession as long as they understand the need to be communicative and compassionate. I see no mention in the article of the students interaction with patients. Is the student respectful, understanding? If they are they will mature and develop into a concerned and caring physician. Team concepts are great. There have always been teams but the physicians were the team captains when it came to patient care. Regardless of what you call them or what letters you use to denote the teams unless the physician is the team leader the care will be mediocre at best.

  • Ken Noguchi

    I think the question here is not whether competitiveness is good or bad, but rather – can medical school educate its students to have better interpersonal skills?

  • Andrew Griffith

    As a patient, find the comments below interesting for the dynamics among doctors. Having interacted with a variety of doctors over the years, most recently for cancer treatment, where teamwork is particularly strong and needed, I have never found the medical expertise to be an issue. I have found differences in empathy and interpersonal skills, fortunately most relating to personal styles (we are human and that makes us interesting), and only the occasional ‘jerk-type’ behaviour. As a patient making difficult treatment choices (my case), the sensitivity of the doctors in handling my concerns and questions was as important as the specific medical recommendation, given the risks involved.
    While I would not go so far as to fail the ‘gunners’ (unless serious ethical breaches like cheating etc), some remedial training and closer monitoring in residency seems appropriate.

  • L Newby

    Gunners will also succeed as part of a team when they see that schools value teamwork as much as other areas which are graded. Gunners succeed at anything which is important. Seems to me that medical schools need to evaluate their programs for the importance and training they give for teamwork principles and procedures before evaluating students who have not been taught or experienced effective teamwork.

  • Suzi Q 38

    Don’t fire the “best” students that work at being the best.

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