Movie buffs and those among us of a certain age remember the 1973 film, The Paper Chase. The film depicted the experiences of John Hart (portrayed by actor Timothy Bottoms) and fellow first-year law students at Harvard. John Houseman won an Academy Award for best supporting actor with his portrayal of Charles Kingsfield, the austere and demanding professor of contract law.

I saw the film a couple years later when I was in high school and came away both intrigued, inspired and a bit shocked by the intellectual culture the film suggested. I was too young to fully appreciate the potential for artistic license in the film’s portrait of the culture surrounding an Ivy League law school and too far removed (geographically, intellectually, experientially) to assess its accuracy. But one take away message was crystal clear—law school represented an academic Bataan death march that only the hardiest could survive. Intellectual casualties were a given…it was just a question of “How many will drop out this year?”

Like most Americans, I didn’t attend law school; nor have I attended medical school. The same is true for my immediate and extended family. Thus, like most members of the public, any assumptions I held about law or medicine for many years were predicated upon little more than notions arising from popular culture such as The Paper Chase, popular television shows and books.

What ill-informed assumptions did I have about medical school? There were two actually.

1. Getting into medical school was difficult—a highly competitive process that weeded many prospects out on the front end.
2. Once you got into medical school, a similar winnowing occurred perhaps not too unlike that depicted in The Paper Chase.

The overall picture I carried around in my head was simple: It’s tough to get into medical school and tough to make it through once you got there.

Fast forward to the late 1990s when a job change brought me into regular contact with medical educators. It did not take long for me to absorb their comments and stories and realize that my fundamental assumptions were only partial correct. Yes, it’s tough to get into medical school…but once you get in, everything about medical school culture is designed to make sure that you come out the other end as a physician. The idea of medical education as an experience featuring heavy attrition was an illusion.

Part of what I absorbed from these colleagues was that the culture permeating U.S. medical schools was best described as a “failure to fail” students—at least, those who for whatever reasons (most likely behavioral issues) should not be passed along to graduate medical education and ultimately patient care.

These colleagues’ stories lamented this reality either explicitly or tacitly—and almost always with a sense of resignation for the futility of any meaningful change in the broader educational culture.

There are plenty of reasons for this failure—culture is just one though admittedly it is probably the strongest. (The words of business guru Jim Collins spring to mind here: “Culture eats strategy for breakfast.”)

Fear and guilt play a role too. Fear of costly litigation seems to underlie many schools’ reluctance to remove the student whose track record has demonstrated their poor fit for medicine—a poor fit usually stemming from ethical or behavioral deficiencies. And guilt? Oh yeah, I’ve heard medical educators shoulder the blame by pointing to failures in the admission process or lack of timely intervention before the student has progressed too far and accrued massive financial debt.

Members of state medical boards—even those not directly involved in medical education—have some sense of this reality. Most of the disciplinary actions they take against licensees have nothing to do with medical knowledge—instead, they invariably involve what one regulator once called the 3 A’s: Arrogance, Avarice and Addiction. It is not uncommon for state medical boards working through a disciplinary case for professional misconduct to become aware that there were early signs of problematic behavior overlooked, minimized, rationalized or otherwise swept under the rug. Maxine Papadakis’ studies from more than a decade ago came as no surprise to medical regulators—the biggest factor associated with later disciplinary action by a state medical board were (mis)behaviors in medical school.* Indeed, I have heard medical regulators complain that it often feels to them that they are having to clean up issues that shouldn’t been dealt by others far earlier in the physician’s career.

For this reason, I find it heartening to see the commentary in a recent New England Journal of Medicine that acknowledges this “dirty little secret” of medical education—though Santeen and her co-authors call out their colleagues more diplomatically by characterizing the culture as one of “kicking the can down the road.” Cultural change is incredibly difficult but it definitely becomes more likely to occur once an issue moves out of the shadows of hallway conversations and after-hour commiserations to the light of public discourse.

* Further evidence of this phenomenon appears in the current ahead-of-print offerings of Academic Medicine by Edward Krupat and colleagues, “Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?”

The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards.