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What happens when medical students witness dehumanization during clinical rotations but feel too powerless to speak up? Kathleen Muldoon, a certified coach and professor in medical education, joins the show to unpack why moral courage is a skill you can practice right now, not something to defer until you hold a title. Based on her KevinMD article “Moral courage in medical training: the power of the powerless,” this conversation reveals how the hidden curriculum in medical training quietly normalizes harm through small, unreported moments. You will hear practical strategies for reclaiming power in clinical hierarchies, from stating your own name to recentering a patient in grand rounds with a single clarifying question. Muldoon explains why kicking moral concerns down the line fuels burnout and erodes professional identity formation, and how attendings can foster psychological safety by modeling vulnerability. If you are a medical student, resident, or physician who has ever felt the gap between what health care should be and what it is, this episode will remind you that middle power is still power.

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Transcript

Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kathleen Muldoon, certified coach and professor in medical education. Today’s KevinMD article is “Moral courage in medical training: the power of the powerless.” Kathleen, welcome back to the show.

Kathleen Muldoon: Thanks for having me, Kevin.

Kevin Pho: All right, so tell us what your latest article is about.

Kathleen Muldoon: My training is actually in anthropology, and through that, I made my way into medical education. I spent a lot of time and years observing medical culture and medical school culture, and moved into the coaching space where a lot of people feel comfortable sharing stories with me that maybe they don’t feel comfortable sharing inside their institutions or within the reporting pathways a lot of the time. Through that, my coaching work has really become aligned with helping people remember where their humanity is and how to remain human in systems that can sometimes force us to feel like we are not humans anymore or make us forget that part of ourselves.

This particular article came together because I was holding a coaching space for students who were coming back from clinical rotations. The stories that they shared with me, I don’t know if they were shocking, but they spoke to something I think we miss in our clinical training. They shared incidents where, for example, even if there were very few students on their rotation, students were referred to as “student one” and “student two” instead of by their names or “Student Doctor” followed by their last name. They shared stories with me, which I think are increasingly common right now, where they are managing not only their curriculum and tuition costs but also food insecurity and housing insecurity themselves. There were other situations where they were in clinical spaces and removed from the role they were meant to have because of the color of their skin. It is not that these students don’t know that is wrong; they do know it is wrong. It is that they don’t know what to do with that information. They are not lacking moral courage, but I think they are experiencing moral isolation in those situations.

In the context of hearing these stories, it was right around the time of the economic forum in Davos where Mark Carney put words to something that I saw reflected in medical education at the time: the concept of middle power. That is when you are embedded within a system, not in control of it, but part of it. This doesn’t necessarily mean that you don’t have influence over how to change the culture or the interaction in that moment, which is a form of power. It is not absolute, top-of-the-shelf power, but it is that middle relational power. This article came together in thinking about how we can apply that to medical education and empower students as they navigate these situations, which are very much a part of the clinical training process.

Kevin Pho: It sounds like those stories where medical students are depersonalized and dehumanized in medical training are still happening today. I think we have talked in the past about how slow medical training is to evolve, and it sounds like some of the remnants, or large parts of the remnants, of how medical training used to be are still going on today.

Kathleen Muldoon: I think it very much is so. I think that this is part of what is usually called the hidden curriculum in medical training. They are not just learning clinical skills or basic science skills, but they are learning how the system works. This is basically handed down silently, often without question, through these small interactions that are left unreported, unnamed, and unquestioned. I think we all have a role in thinking about what our power is in relationship to changing that.

Kevin Pho: From the perspective of a medical student, I could only imagine that one of the reasons they don’t push back a little bit is that they are concerned about their medical careers. There are some analogous similarities to the military where people lower on the totem pole are afraid to speak out against power. When these students come to you after their clinical rotations, what kind of advice do you give them?

Kathleen Muldoon: I think it is really important to validate that their feelings are appropriate and to acknowledge that yes, they are seeing some of the parts of the health care system that are broken. I will use the word “broken.” What does it mean to come into a system with these high moral values of wanting to help people and wanting to change the system and make it better, only to be met with the reality that the system is broken and there are constraints on what we can do? The first step is always validating that what they are noticing is a misalignment of what they thought medicine was going to be like and what they are experiencing. I think we can all think of examples where we have experienced that ourselves.

The second thing is to remind them of the power that they do have. For example, the student who told me she was referred to as “student one” on her clinical rotation does have power when she goes in to do her history taking or even when she is in conversation with that attending. She can remind them: “Actually, my name is Student Doctor Sarah,” or “I’d like to introduce myself to you; my name is Student Doctor [last name].” That is a form of standing your ground and being honest about your name. It could feel like a small challenge, and let’s just stand in the truth that a student could feel fearful that stating their name could be seen as a challenge. But there is nothing wrong with saying your name when you are in a clinical situation like that. We normalize for them that yes, that is a form of harm, and stating your name is actually a really powerful way of taking your power back.

I can give another situation where in grand rounds, an interprofessional team was being dismissive of a patient. In that situation, the student does not hold the most power, but they can ask a clarifying question such as: “I’m wondering how we are centering the patient’s goals here,” or “Can I summarize? In my own words, what I hear are the patient’s goals,” which then recenters the patient and gets back to the actual mission of the team, which is partnering in promoting individual persons’ health. These actions don’t require heroics, but they do need validation that their feelings are important and correct, and that there are small strategies that create influence on the interaction, which is a form of power.

Kevin Pho: I like the way you phrased that in the anecdote you just shared, starting with: “I wonder how the patient can be in the center.” I have heard this in other podcasts as well: whenever you want to bring up something, starting with “I wonder,” “I noticed,” or “I observed” and couching it that way can bring up some of those issues without appearing overtly argumentative.

Kathleen Muldoon: Exactly right. I am very much aware of the power structure within medical hierarchies. I think these strategies don’t minimize the role of the student or somebody who is not in a position of power in leading those meetings, and yet it does influence the attention of the group. For those reasons, I think they are really important for people to practice. I think that is another important point: moral courage isn’t something that you have or you don’t have; it is something that we consistently practice. When you practice something, you are building a skill. Sometimes it might feel scary and sometimes it might not land exactly the way you want, but the value is in practicing and building that skill so it becomes second nature.

Kevin Pho: You wrote in your article that sometimes waiting until students become attendings to practice moral courage is a dangerous myth. Explain why that is.

Kathleen Muldoon: I think there is this myth that because you are in a space where you are not in charge of the system, you have no power. As we know, a lot of institutions and cultures not only take a long time to change, but change from the inside out, from the people who are practicing it and notice these misalignments and take action. The reason why waiting until you have power is dangerous is that I actually see a lot of students and trainees do this. They kick the issue down the line, thinking: “I’ll do that when I am in the clinics,” or “I’ll do that when I’ve matched,” or “I’ll do that when I’m an attending.” You are adding years onto the time when you think that you have a voice in the system.

What does that do to you and your professional identity formation? That is going to have an effect because it is a form of making yourself small. These are all things that contribute to burnout. The second thing I want to point out is asking what we are normalizing when we do that. Silence is not neutrality; it conveys a normalization of some of these forms of moral misalignment. I can think of several examples that we have talked about and that have come up in your podcast before, such as that exhaustion is a form of resilience in medicine, or that staying silent when you see things like this is a form of professionalism. I think that especially for trainees, who hold the power of the future of the profession in their hands, calling these things to attention and validating their concerns is important. It is not that they don’t know it is wrong; it is just that they don’t know what to do with that information. We can help them learn what to do with that information just by validating and being honest that this is something we need to call attention to now.

Kevin Pho: How much is it incumbent on the student to speak up or gently push back, and how much is it that those in power need to change? Do you see any work being done for those in power to sometimes change the way they treat medical students during clinical rotations?

Kathleen Muldoon: Absolutely. I think there is a large role that attendings and administrators in medical education institutions could assume here. One of the lessons that we are still working on how to impart during medical training is how to say: “I don’t know,” or “I agree that feels misaligned,” or even “That was a mistake.” That is not a failure. That is recognizing and validating something that we are noticing because we love medicine and we think this is a valued institution. Pointing those things out and normalizing that if you are the attending is very powerful for creating psychological safety in your learning environment.

As medical education is evolving, we are seeing a revision in competencies towards making sure that there is a therapeutic use of self, that you are constantly reflecting on how you influence a space, and what professionalism means. Staying in alignment with those things and allowing yourself to respond to the changing landscape within medical education right now is a huge part of continuing medical education. Acknowledging it would be really wonderful for creating humanizing spaces in those clinical training situations. So the power is not entirely on the student, but the students are leading the way in saying: “Hey, we are entering this as full human beings and a lot of times not as empty vessels that have no experience with the health care system.” A lot of students these days come in having years of experience as medical scribes or medical assistants, so they have seen versions of these interactions before.

They come in knowing that they want to be part of the future of medicine. When they call these things out and notice them, which they may not feel comfortable doing, they may do it in more safe spaces, journal it to themselves, or bring it to you because they feel like it is a safe space. They do it because they love medicine. How do we check our own reactions that might feel defensive and say: “I’m feeling this because I also love medicine; how can we work together to normalize and change some of these things that we both see as needing change?”

Kevin Pho: Sometimes when students point out or notice the way they are treated, it could lead to some uncomfortable moments. One of the things that you wrote in your article was that staying present and curious during these uncomfortable moments is a core clinical skill. Talk to us more about that.

Kathleen Muldoon: I think one of the things that I see students, attendings, and some of the physicians that I work with in the coaching space struggle with is remembering that being in medicine means you are signing up for uncomfortable situations. The ones that come to mind are end-of-life conversations and clinical decisions, but this is no different. Nobody said that conversations are going to be easy; they are courageous. This is a conversation that we have had before. I think this is another part of that skillset: how do we remain curious and comfortable with the fact that we are going to be uncomfortable and have emotional reactions in multiple situations?

The power then lies in the technique of what you do when you feel that. Remember, this is part of the full humanity of bringing your full self wherever we are. You are going to have emotional reactions in the clinical space. So, pause. I know you only have 15 minutes, but that is still enough time to pause, notice that your heart is pounding a little and your blood pressure is rising, and remind yourself that this is because this is important to you. It might feel like a challenge, but it is important to move that conversation forward and create the clinical space that you want and that your patients deserve.

Kevin Pho: We are talking to Kathleen Muldoon. She is a certified coach and professor in medical education. Today’s KevinMD article is “Moral courage in medical training: the power of the powerless.” Kathleen, as always, we will end with some take-home messages that you want to leave with the KevinMD audience.

Kathleen Muldoon: I think for your audience of clinicians and clinicians in training, I would like to remind everybody that, especially in the clinical years, students are learning clinical skills, of course. But they are also learning the hidden curriculum of what we normalize and what we accept in medicine and for the future of medicine that we all want. I think it is important to be present and stay curious. When we notice those points of moral misalignment, think about how even if you can’t change the whole system, and even if we continue to work in systems that can feel harmful at times, we do so because we love it and because we think of the benefits of medicine for all people who interact with it. Stay curious in those moments where people bring those observations to us and remember that we all have a role to play in influencing it.

Kevin Pho: Kathleen, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Kathleen Muldoon: Thank you so much for having me.