We are nearing the end of the academic year, and I recently found myself standing in front of a room of first-year medical students offering what I called “observations.” Not punishments. Not a lecture. Observations. And an invitation. Because what I had been seeing was concerning: academic dishonesty, inappropriate use of artificial intelligence (AI), emotional volatility, and a level of disengagement that felt at odds with a curriculum intentionally designed for presence and reflection. It would be easy to stop there. To name the behavior and move quickly to consequences. To tighten policies, increase surveillance, and call it professionalism. But that approach, while satisfying in the short term, misses the more important question: What is this behavior telling us?

When learners begin outsourcing their thinking to AI, to answer keys, to whatever gets them through to the end of the task, we should be asking not only what they are doing, but what we have taught them to value. In medicine, we ask patients to trust evidence-based recommendations. We ask them to reconsider what they see on social media, to question misinformation, to believe that our training equips us to guide them. But what happens when, in our own medical training environments, students are not practicing intellectual honesty? When they are rewarded, implicitly or explicitly, for efficiency over inquiry, performance over presence, correctness over curiosity? We should not be surprised when they optimize for the system we have built.

Somewhere along the way, many students internalize a quiet but powerful equation: Being “good” means being right. Being right means not failing. And not failing means avoiding risk at all costs. Including giving their thinking away. Including giving their humanity away. And we reinforce this every time we over-measure, over-grade, and reduce complex human development to a number, a percentile, or a pass/fail threshold that is anything but neutral in its hidden curriculum.

The cost of prioritizing performance over curiosity

Recently, I spoke with residency leaders who shared a story that has stayed with me. A student was an exceptional candidate on paper. Strong scores. Leadership. All the right experiences. Yet, on his audition rotation, something did not translate. He was not curious; he was certain. He corrected rather than inquired. And, he was not ranked. In the language of residency selection, he received a do not rank (DNR). He did not match. That was his feedback. Not a comment on an evaluation. Not a grade. A life-altering outcome.

We often tell students that professionalism, curiosity, and humility matter. Yet, the environments we create frequently signal that measurable achievement matters more. Until suddenly, it does not. And by then, it is too late. So when I see disengagement or academic dishonesty in a discussion-based course, I try to resist the instinct to interpret it as apathy or moral failure. Instead, I ask: What rational decisions are students making inside an irrational system? What happens when learners are trained in environments where their worth is continuously quantified, where success is narrowly defined, and where failure feels existential? What happens when those same learners enter a space that asks for something different: presence, reflection, intellectual risk, and honest engagement?

Of course there is friction. A course in courageous conversation, at its best, is not an “easy” course. It is a rare one. It creates space, if we protect it, for students to practice becoming the kind of physicians they hope to be. It offers room to fail forward, to think independently, to engage with uncertainty. But that space only works if students trust it. And trust is fragile in systems that have repeatedly told them that every misstep is consequential. So they hedge. They optimize. They protect themselves. And sometimes, they stop thinking.

Reclaiming intellectual honesty and presence

The cost of that is not just academic integrity. It is something far more important. It is the erosion of curiosity. Without curiosity, there is no listening. Without listening, there is no trust. And without trust, there is no meaningful patient care. Patients do not need perfect physicians. They need trustworthy ones. Clinicians who can sit with uncertainty, who are honest about what they know and do not know, and who remain open to learning. Those capacities are not developed through performance alone. They are cultivated through environments that reward inquiry, tolerate discomfort, and model intellectual humility.

If we are serious about training physicians who can meet the complexity of modern medicine, then we must look beyond individual student behavior and examine the systems we have built. We must ask ourselves:

• What are we incentivizing?
• What are we measuring?
• And what are we unintentionally teaching when students feel that the safest path is to disengage, outsource, or simply get through?

Medical educators have an opportunity, and a responsibility, to recalibrate. This does not mean lowering standards. It means clarifying them. It means creating learning environments where honesty is safer than performance, where curiosity is explicitly valued, and where students are invited, not just told, to take ownership of who they are becoming. It also means aligning as faculty. Students are exquisitely attuned to mixed messages. When one part of the curriculum asks for reflection while another rewards only efficiency and correctness, learners will follow the incentives, not the ideals.

We cannot ask students to become thoughtful, present, and trustworthy physicians if we do not consistently model and reward those behaviors. A reorientation is needed. Not just for students, but for all of us. From performance to purpose. From certainty to curiosity. From individual achievement to shared responsibility. We are not just teaching students how to pass exams. We are shaping how they will think, how they will listen, and how they will show up for patients in moments that matter. The question is not only what our students are doing. It is who our systems are allowing them to become. And whether we are willing to change that.

Kathleen Muldoon is a certified coach dedicated to empowering authenticity and humanity in health care. She is a professor in the College of Graduate Studies at Midwestern University – Glendale, where she pioneered innovative courses such as humanity in medicine, medical improv, and narrative medicine. An award-winning educator, Dr. Muldoon was named the 2023 National Educator of the Year by the Student Osteopathic Medical Association. Her personal experiences with disability sparked a deep interest in communication science and public health. She has delivered over 200 seminars and workshops globally and serves on academic and state committees advocating for patient- and professional-centered care. Dr. Muldoon is co-founder of Stop CMV AZ/Alto CMV AZ, fostering partnerships among health care providers, caregivers, and vulnerable communities. Her expertise has been featured on NPR, USA Today, and multiple podcasts. She shares insights and resources through Linktree, Instagram, Substack, and LinkedIn, and her academic work includes a featured publication in The Anatomical Record.