Integrity – The Crucial Characteristic

This article was originally posted in our April 2017 Newsletter, by Doug Smith, CEO, Medical Educator

Imagine a scene where you are a seasoned practitioner, who is at home with your 6-year-old daughter, and she experiences an asthma attack. She has a history of this occurring, but your spouse is out refilling the prescription and you have used the only dose available with no real improvement. You call the local EMS agency who sends a crew to your location. Your expectation is they will bring a nebulized breathing treatment to correct the bronchospasms. The crew who arrives is made up of a paramedic and basic EMT. Unknown to you, this paramedic obtained his license by cheating on his tests to get through the program and to obtain his licensure.

You provide the team with the history and your request for a nebulizer treatment. Unfortunately, this particular team is unfamiliar with administering medications though a nebulizer but seems to recall something about administering Epinephrine as always being safe with children. He draws up 0.1 mg/kg to administer IV. The correct dose should be 0.01 mg/kg, administered IV with a maximum dose of 0.3 mg for a severe status asthmaticus event which you do not believe it has reached that level even though your daughter is appearing alert and anxious. Your daughter weighs about 45 pounds or 20 kilograms. The paramedic draws up the Epinephrine and is about to administer the medication when you intercede to stop him. You recognize this is over 10 times the appropriate amount and the incorrect route even if the medication was indicated.

In response, the EMS team calls law enforcement and accusing you of interfering with them performing their duties and further claims your action is endangering your child. The police place you in custody and the paramedic proceeds to administer the medication which results in serious consequences.

Let us examine where this scenario went so wrong. We can all feel comfortable that the paramedic did not start the program with the intent of causing problems for a 6-year-old child. What I believe is very clear is that the paramedic lost sight of the entire purpose of the training program. The reason of a training program to becoming a healthcare provider is so that you can be a competent and confident caregiver. The process of cheating destroys both of those purposes as the cheater knows that they have cheated and thereby reduce their confidence. Borrowing the information to pass a test does not ensure the acquisition of knowledge so competence also suffers. The purpose of an examination is to discriminate those who know the material from those who only have a slight acquaintance, at best, with the material. When they cheat at an exam they invalidate the examination and the exam can no longer perform properly.

If we constantly keep in mind that the purpose of the training is to learn the material so that we can provide competent confident care and not just to pass the test we will achieve both. For a competent confident provider will pass the test, but passing the test does not ensure that you are competent and confident. And, in fact, if they cheat on the exam they will very likely erode their own competence and confidence. The lack of confidence and competence results in insecurity in the provider which then results in inappropriate responses to stressful situations.

What if a pilot were to have a focus of passing the test but not focusing on becoming a confident competent pilot? You would certainly not want to get on a plane with one of these individuals and, in fact, the pilot would not want to either. Learners often rationalize that our cheating is okay as we promise to learn it later but we just need to get through the test now. We believe the price of studying and learning is too high right now and we will pay it later. The problem is learning it later rarely happens in a timely fashion. It usually happens that the lesson is learned at a considerable cost. In the case of the pilot or healthcare provider, the cost of this lesson could easily be someone’s life.

Much of the cheating culture has been engrained in our student’s code at an early age. The focus to get good grades and to get through the program is more important than learning the material. This comes from parental and school reward programs. We hear of cheating scandals involving state testing evaluations to make sure a school is meeting its marks to even the military academies.

How can you prevent cheating? This is a question that is often asked but should instead be rephrased to ask, “How do we create a culture where the student would rather learn the material than to cheat?” Often you hear the comment after the cheater is caught that “If they just would have put this energy into learning the material, they would not have needed to cheat.” The problem is not based on time or energy but instead how that time and energy is invested. Instead of expecting high grades on formative exams, in other words creating an atmosphere that encourages and rewards cheating, let’s focus on a system where the expectation for formative grades are low, the thought that the student rarely gets it correct the first time, and instead focus on allowing the student to learn from their mistakes.

The penalty for cheating should be severe, but the motivation to cheat needs to be reduced so that the focus becomes learning the material to be a competent and confident provider and not just “passing the test”. The price for any other course of action is just too high.