Well-Being of Students
Medical Students’ Experiences of Moral
Distress: Development of a Web-Based Survey
Catherine Wiggleton, MD, Emil Petrusa, PhD, Kim Loomis, MD, John Tarpley, MD,
Margaret Tarpley, Mary Lou O’Gorman, MDiv, and Bonnie Miller, MD
Abstract
Purpose
To develop an instrument for measuring
moral distress in medical students,
measuring the prevalence of moral
distress in a cohort of students, and
identifying the situations most likely to
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cause it. Moral distress, defined as the
negative feelings that arise when one
knows the morally correct thing to do
but cannot act because of constraints or
hierarchies, has been documented in
nurses but has not been measured in
medical students.
Method
The authors constructed a survey
consisting of 55 items describing
potentially distressing situations.
Responders rated the frequency of these
T he practice of medicine is
fundamentally a moral endeavor. As
argued by Pellegrino,1 knowledge and
expertise place the physician in a position
of authority, and illness places the patient
Dr. Wiggleton is resident, Department of
Pediatrics, Vanderbilt University School of Medicine,
Nashville, Tennessee.
Dr. Petrusa is director, Office for Teaching and
Learning in Medicine, Center for Outcomes and
Research in Education, Vanderbilt University School
of Medicine, Nashville, Tennessee.
Dr. Lomis is assistant professor, Department of
Surgery, Vanderbilt University School of Medicine,
Nashville, Tennessee.
Dr. Tarpley is professor, Department of Surgery,
Vanderbilt University School of Medicine, Nashville,
Tennessee.
Ms. Tarpley is associate in surgery, Department of
Surgery, Vanderbilt University School of Medicine,
Nashville, Tennessee.
Ms. O’Gorman is director of pastoral care, St.
Thomas Hospital, Nashville, Tennessee.
Dr. Miller is senior associate dean for health
sciences education, Vanderbilt University School of
Medicine, Nashville, Tennessee.
Correspondence should be addressed to Dr. Miller,
201 Light Hall, Vanderbilt University School of
Medicine, Nashville, TN 37232-0685; telephone:
(615) 343-7536; e-mail: bonnie.m.miller@
vanderbilt.edu.
Academic Medicine, Vol. 85, No. 1 / January 2010
situations and the intensity of distress
that they caused. The survey was
administered to 106 fourth-year medical
students during a three-week period in
2007; the response rate was 60%.
Results
Each of the situations was experienced
by at least some of the 64 respondents,
and each created some degree of moral
distress. On average, students witnessed
almost one-half of the situations at least
once, and more than one-third of the
situations caused mild-to-moderate
distress. The survey measured individual
distress (Cronbach alpha ⫽ 0.95), which
varied among the students. Whereas
women witnessed potentially distressing
situations significantly more frequently
in a position of vulnerability and need.
This unbalanced relationship creates a
moral imperative: Physicians must
uphold the promise to use their skills in
service to their patients, and they must be
mindful and principled in negotiating the
conflicts of interest that arise on a daily
basis.2 The moral development of medical
students should thus be considered a
matter of high priority for medical
educators. Using validated instruments that
measure stages of moral reasoning,
investigators have found, however, that
medical students do not show the progress
that would be expected in others of
similar age and educational level. Some
students may, in fact, regress.3,4 The
question then arises as to whether the
process of medical education impedes
rather than promotes moral growth.5
For seven years, we sponsored monthly
meetings of medical students and faculty,
in which students described experiences
on their clinical rotations that raised
ethical or moral questions. Participation
in these sessions was voluntary, and the
students were assured that these meetings
provided a safe haven for frank
discussion. The accumulated body of
stories supported the notion that
than did men (P ⫽ .04), men tended to
become more distressed by each event
witnessed (P ⫽ .057).
Conclusions
Medical students frequently experience
moral distress. Our survey can
be used to measure aspects of the
learning environment as well as
individual responses to the environment.
The variation found among student
responses warrants further investigation
to determine whether students at either
extreme of moral distress are at risk of
burnout or erosion of professionalism.
Acad Med. 2010; 85:111–117.
students struggle with moral issues on a
regular basis. Specifically, students
reported that they had a strong desire to
do what they thought was in patients’
best interests, but they were frustrated by
a variety of obstacles, including systems
of care, the hierarchy of medical
education, and conflicts with patients’
own values and wishes. These stories
were recounted with a sense of distress
and sometimes anguish. One might
expect that the students’ position at the
bottom of the medical hierarchy would
absolve them of a sense of responsibility
for the situations they encountered, but,
paradoxically, it seemed to heighten that
sense, because they often felt that they
were the only ones who cared. If they
didn’t act, then who would?
In 1984, Jameton6 described the concept
of moral distress, defining it as the
negative feelings that arise when one
knows the morally correct response to a
situation but cannot act because of
institutional or hierarchal constraints. He
also said that episodes of moral distress
are distinct from moral dilemmas, which
involve decisions between two potentially
correct courses of action and which are
not always accompanied by negative
111
Well-Being of Students
emotional responses.7 Nurses are felt to
be particularly prone to moral distress
because of their direct responsibility for
patient care combined with their lack of
ultimate decision-making authority.
Using instruments constructed to measure
moral distress, investigators have shown
that it can ultimately affect a nurse’s
capacity for caring and that it is linked to
withdrawal from patient contact, burnout,
and attrition from the profession.8 –11
The physician literature contains much
less about moral distress. Using focus
group methodology, Kalvemark et al12
showed that moral distress occurs in
physicians, nurses, and pharmacists in
the context of ethical dilemmas and
resource constraints, and that it might
occur even when one acted on conscience
but violated policies or regulations.
Hamric and Blackhall13 recently devised a
scale by which to measure moral distress
in physicians and nurses who deliver end-
of-life care in intensive care units. They
found that both nurses and physicians
experience moral distress, especially in
cases of prolonged and futile care. Higher
moral distress scores correlated with less
job satisfaction in nurses and subsequent
risk of attrition, but the numbers were
too small to show the same relationships
in physicians.13 It seems logical that
moral distress would occur in medical
students, who simultaneously witness
and participate in the moral quandaries
that arise in patient care. They feel a
laudable sense of responsibility for their
patients, but they are constrained from
action by their position in the hierarchy
and their valid concern for subsequent
evaluations. In this study, we aimed to
construct an instrument that measures
moral distress in physicians-in-training,
to determine the extent of this
phenomenon in a cohort of students, and
to determine the types of situations most
likely to elicit this response.
Method
Survey development
For moral distress to occur, two elements
must be present: a situation or episode
that is perceived as morally incorrect, and
a context that constrains one from taking
corrective action. In developing our
survey, we considered both elements.
Corley14 developed a moral distress scale
for the nursing profession that has been
shown to be reliable and valid. A few of
112
its items were applicable to students, and
we obtained permission to adapt these
items for use in our survey. We generated
additional items from a review of the
stories told by our students during the
voluntary meetings of the past seven
years. Finally, we conducted a review of
the literature using the PubMed database.
We used the search terms “moral distress,”
“moral dilemma,” and “ethical dilemma,”
and we limited results to those that
focused on medical education.15–18 This
process resulted in a total of 50
potentially distressing situations.
For each situation, respondents rated the
frequency of its occurrence and the
degree of resulting distress. Frequency
ratings used a five-point scale: 0 ⫽ never,
1 ⫽ infrequently, 2 ⫽ occasionally, 3 ⫽
frequently, and 4 ⫽ very frequently.
Distress ratings used a four-point scale:
0 ⫽ no distress, 1 ⫽ mild distress, 2 ⫽
moderate distress, and 3 ⫽ severe
distress. The distress scale also had the
option of “no distress because it never
happened.” For both scales, response
options were labeled. The instrument
included a definition of moral distress,
and respondents were asked to limit their
responses to clinical experiences during
the past year.
In considering causes for student inaction
when, in theory, some action could be
taken, we focused on the students’
position in the hierarchy of medical
education. The literature and our own
experience suggested that fear for grades,
concern for one’s relationship with team
members, and insecurity regarding
personal knowledge and skills block a
student’s impulse to act.17,19 At the end of
the survey, we included six items regarding
these reasons, and we asked the students to
rate them according to the five-point
frequency scale described above.
After initial construction of the
instrument, we convened a focus group
of eight fourth-year medical students
who volunteered in response to an e-mail
request sent to the entire class. They
completed the survey and immediately
discussed their reactions; they also
provided feedback on the clarity and
organization of the survey and suggested
additional situations that, in their
experience, had created moral distress.
We also obtained input from selected
faculty members, both within the medical
school and from other university
Academic Medicine, Vol. 85, No. 1 / January 2010
departments, who were known to have
expertise in biomedical ethics and/or
survey design. On the basis of this
feedback, we revised the initial item set
to produce a survey version with 55
discrete situations.
Study design
We offered the Web-based survey to the
entire fourth-year class during a three-
week period in March 2007. This sample
of 106 students did not include the eight
focus group participants. An e-mail
provided an explanation of the study as
well as a link to the survey. We included
an informed consent document at the
beginning of the survey, and we assured
students that their responses would
remain anonymous. Written consent was
not required, because subsequent
completion of the survey implied that
consent was given. Nonresponders were
sent periodic reminders. As an incentive
to participate, respondents were included
in a raffle for a variety of prizes, ranging
in value from movie tickets to iPod
nanos. The study received exempt status
from Vanderbilt University School of
Medicine’s institutional review board.
Statistical analysis
We used SPSS software (version 15.0;
SPSS Inc., Chicago, Illinois) to analyze
the data, including the frequency of and
distress ratings for each individual
situation. To evaluate individual
students, we summed each student’s
frequency ratings and distress ratings and
created a scatterplot. We calculated
Cronbach alpha to determine the
suitability of the scale for assessment of
individual situations. We reviewed men’s
and women’s total frequency scores, total
distress scores, mean distress scores per
situation, and mean frequency scores per
situation to ascertain whether there were
differences according to gender.
Results
Sixty-four of the 106 medical students
completed the survey, for a 60%
response rate. Sixty (83%) of the
responding students were between 25
and 29 years old. Thirty-three (52%)
were female, and 31 (48%) were male.
Relative to the whole class of 51 women
and 55 men, women were more likely
to respond than were men, with
response rates of 65% and 56%,
respectively. There was no correlation
 Well-Being of Students

between the age of the respondent and scale). Table 1 shows the frequency of items that appear in both tables are
frequency or distress. Gender occurrence of and the distress ratings for footnoted in each table.
differences are reported below. these situations in the order of frequency
(mean frequency for all items ⫽ 1.0). Individual students’ moral distress
Analysis of individual situations Nineteen (35%) of the 55 situations in We also examined the differences
Nearly half (n ⫽ 26) of the situations the survey caused at least mild-to- between the responses of individual
included in the survey had a mean moderate distress. Table 2 shows the students, calculating an overall distress
frequency greater than 1.0, which meant frequency of occurrence of and the score as well as the relationship between
that, on average, students witnessed these distress ratings for these 19 situations, in frequency of a situation and the resulting
situations at least once (referred to as order of the degree of distress (mean distress. We computed distress scores (d)
“infrequently” in the five-point rating distress for all items ⫽ 1.5). The eight by adding the distress ratings (from the

Table 1
Frequency of Situations That Occurred at Least Once, Ranked From Most Often
to Least Often, and Corresponding Mean Distress Scores From a Cohort of 64
Fourth-Year Medical Students, Vanderbilt University School of Medicine, 2007*

Frequency: Distress:
Situation mean (SD) mean (SD)
Members of my team “bad-mouthed” other services. 2.70 (0.97) 0.95 (0.66)
...................................................................................................................................................................................................................................................................................................................
A member of my team made disparaging or demeaning comments about a patient who was overweight or obese. 2.20 (1.04) 1.16 (0.87)
...................................................................................................................................................................................................................................................................................................................
A patient presented with very advanced disease because he or she faced barriers to accessing care.† 2.14 (0.89) 1.90 (0.76)
...................................................................................................................................................................................................................................................................................................................
Multiple providers were involved in the care of one of my patients, and, because their roles were not fully 2.14 (1.11) 1.34 (0.82)
explained, there was confusion on the part of the patient and/or family.
...................................................................................................................................................................................................................................................................................................................
Over the course of a patient’s hospitalization, he or she was cared for by multiple doctors and services, which led to 1.95 (1.20) 1.50 (0.76)
fragmented, discontinuous care.†
...................................................................................................................................................................................................................................................................................................................
A member of my team made disparaging or demeaning remarks about one of our patients. 1.83 (0.94) 1.18 (0.76)
...................................................................................................................................................................................................................................................................................................................
A member of my team was disrespectful to someone below himself or herself on the team ranking.† 1.70 (1.11) 1.86 (0.81)
...................................................................................................................................................................................................................................................................................................................
The attending physician or resident answered a patient’s questions inadequately or simply ignored them.† 1.66 (1.04) 1.50 (0.73)
...................................................................................................................................................................................................................................................................................................................
A member of my team made disparaging or demeaning comments about a patient who was a smoker. 1.64 (1.04) 0.72 (0.74)
...................................................................................................................................................................................................................................................................................................................
I withheld information from a patient who requested it, because I felt it was not my responsibility or place to 1.61 (1.15) 1.37 (0.77)
provide it.
...................................................................................................................................................................................................................................................................................................................
Poor communication between multiple teams that were collaborating in the care of one my patients negatively 1.53 (0.91) 1.67 (0.79)
affected his or her care.†
...................................................................................................................................................................................................................................................................................................................
I promised one of my patients that someone would come back to talk to him or her, even though I was not sure it 1.45 (1.14) 1.35 (0.69)
would actually happen.
...................................................................................................................................................................................................................................................................................................................
Optimal care was not provided to one of my patients because of language barriers.† 1.42 (0.85) 1.53 (0.76)
...................................................................................................................................................................................................................................................................................................................
I participated in “bad-mouthing” another service. 1.42 (1.00) 0.83 (0.69)
...................................................................................................................................................................................................................................................................................................................
Delays occurred in the performance of tests or procedures because of scheduling problems or lost requests, and 1.41 (1.00) 1.47 (0.72)
this resulted in suboptimal patient care.
...................................................................................................................................................................................................................................................................................................................
Suboptimal care was provided to a patient because our team was too tired and overworked. 1.41 (1.11) 1.47 (0.74)
...................................................................................................................................................................................................................................................................................................................
The team went along with a treatment that we did not believe was indicated, because an attending insisted on it. 1.38 (0.98) 1.14 (0.75)
...................................................................................................................................................................................................................................................................................................................
A member of the team gave incorrect or uncertain information on rounds, but I said nothing. 1.38 (0.97) 0.96 (0.70)
...................................................................................................................................................................................................................................................................................................................
A member of my team was disrespectful to the nursing and/or ancillary staff. 1.31 (0.96) 1.37 (0.87)
...................................................................................................................................................................................................................................................................................................................
Delays in the return of laboratory data or radiology reports negatively affected the patient. 1.30 (1.02) 1.44 (0.81)
...................................................................................................................................................................................................................................................................................................................
Optimal care was not provided to a patient because of insurance status.† 1.20 (1.22) 1.67 (0.93)
...................................................................................................................................................................................................................................................................................................................
Optimal care was not provided to a patient as a result of stigmatizing social circumstances or conditions (e.g., 1.16 (1.06) 1.42 (0.79)
alcoholism, drug abuse, homelessness, or obesity).
...................................................................................................................................................................................................................................................................................................................
Our team continued to provide therapy at the patient’s or family’s request, even though I thought it only prolonged 1.14 (1.08) 1.85 (0.79)
the patient’s suffering.†
...................................................................................................................................................................................................................................................................................................................
A patient was discharged before I thought it was safe, because there was no one at home to care for the patient. 1.11 (0.97) 1.39 (0.87)
...................................................................................................................................................................................................................................................................................................................
I made disparaging or demeaning remarks about one of my patients. 1.03 (0.85) 1.14 (0.90)
...................................................................................................................................................................................................................................................................................................................
An attending and/or resident misrepresented the degree of my experience in performing a procedure. 1.03 (0.98) 1.12 (0.81)
* The wording “at least once” equals the ranking term “infrequently.” Respondents completed a survey
composed of 55 situations; they were asked to specify the frequency with which each situation occurred, by
using a five-point scale (0 ⫽ never, 1 ⫽ infrequently, 2 ⫽ occasionally, 3 ⫽ frequently, and 4 ⫽ very frequently),
and the degree of moral distress the situation caused, by using a four-point scale (0 ⫽ none, 1 ⫽ mild distress,
2 ⫽ moderate distress, and 3 ⫽ severe distress). Definitions for each degree of distress were provided at the
beginning of the survey. A score of “at least once” corresponds to a mean frequency of ⱖ1.0.
†
This item is also listed in Table 2.

Academic Medicine, Vol. 85, No. 1 / January 2010 113

 Well-Being of Students

Table 2
Situations That Occurred at Least Once, Presented in Order From High to Low
Reported Distress Rankings, and Corresponding Mean Frequency Scores From a
Cohort of 64 Fourth-Year Medical Students, Vanderbilt University School of
Medicine, 2007*

Distress: Frequency:
Situation mean (SD) mean (SD)
A patient presented with very advanced disease because he or she faced barriers to accessing care.† 1.90 (0.76) 2.14 (0.89)
...................................................................................................................................................................................................................................................................................................................
One of my superiors behaved inappropriately, but I did not report it because I was afraid it would affect 1.89 (0.98) 0.98 (0.96)
my evaluation.
...................................................................................................................................................................................................................................................................................................................
A member of my team was disrespectful to someone below himself or herself on the team ranking.† 1.86 (0.81) 1.70 (1.11)
...................................................................................................................................................................................................................................................................................................................
Our team continued to provide therapy at the patient’s or family’s request, even though I thought it only 1.85 (0.79) 1.14 (1.08)
prolonged the patient’s suffering.†
...................................................................................................................................................................................................................................................................................................................
I felt that a patient was discriminated against by a member of my team on the basis of gender, race, 1.82 (0.88) 0.34 (0.62)
sexual orientation, or religion.
...................................................................................................................................................................................................................................................................................................................
An error was made in the care of one of my patients that was not fully or truthfully disclosed. 1.74 (0.64) 0.83 (0.81)
...................................................................................................................................................................................................................................................................................................................
One of my superiors behaved inappropriately, but I did not report it because I did not believe it was my 1.70 (0.88) 0.94 (0.94)
place to do so.
...................................................................................................................................................................................................................................................................................................................
I performed a procedure that I did not feel qualified to do, because I was afraid of being perceived as 1.68 (0.85) 0.47 (0.67)
incompetent.
...................................................................................................................................................................................................................................................................................................................
Optimal care was not provided to a patient because of insurance status.† 1.67 (0.93) 1.20 (1.22)
...................................................................................................................................................................................................................................................................................................................
Our team withdrew life support at the patient’s or family’s request, even though I thought the patient 1.67 (1.12) 0.19 (0.50)
could have survived with continued treatment.
...................................................................................................................................................................................................................................................................................................................
Poor communication between multiple teams that were collaborating in the care of one my patients 1.67 (0.79) 1.53 (0.91)
negatively affected his or her care.†
...................................................................................................................................................................................................................................................................................................................
A member of my team was rude and disrespectful to a patient or family member. 1.64 (0.88) 0.98 (0.81)
...................................................................................................................................................................................................................................................................................................................
I believe that a patient did not receive the standard of care for his or her condition. 1.64 (0.67) 0.78 (0.77)
...................................................................................................................................................................................................................................................................................................................
I performed a procedure that I did not feel qualified to do, because I felt pressured by a resident or 1.60 (0.88) 0.44 (0.73)
attending.
...................................................................................................................................................................................................................................................................................................................
Our team continued life support, even though I thought it was not what the patient would have 1.56 (0.85) 0.67 (0.94)
wanted.
...................................................................................................................................................................................................................................................................................................................
A patient was discharged before I thought it was medically safe. 1.54 (0.78) 0.52 (0.76)
...................................................................................................................................................................................................................................................................................................................
Optimal care was not provided to one of my patients because of language barriers.† 1.53 (0.76) 1.42 (0.85)
...................................................................................................................................................................................................................................................................................................................
Over the course of a patient’s hospitalization, he or she was cared for by multiple doctors and services, 1.50 (0.76) 1.95 (1.20)
and this led to fragmented, discontinuous care.†
...................................................................................................................................................................................................................................................................................................................
The attending physician or resident answered a patient’s questions inadequately or simply ignored 1.50 (0.73) 1.66 (1.04)
them.†
* The wording “at least once” equals the ranking term “infrequently.” Respondents completed a survey
composed of 55 situations and were asked, for each situation, to report the frequency with which it occurred,
by using a five-point scale (0 ⫽ never, 1 ⫽ infrequently, 2 ⫽ occasionally, 3 ⫽ frequently, and 4 ⫽ very
frequently), and the degree of moral distress it caused, by using a four-point scale (0 ⫽ no distress, 1 ⫽ mild
distress, 2 ⫽ moderate distress, 3 ⫽ severe distress). Definitions for each degree of distress were provided at the
beginning of the survey. Mild-to-moderate distress corresponds to a mean distress rating of ⱖ1.5 (where 1 ⫽
mild distress, and 2 ⫽ moderate distress).
†
This item is also listed in Table 1.

four-point scale) given to all items by an is 0.95, which indicates very high internal frequency rating per situation than did
individual student. With 55 items and a consistency. men (1.19 [SD: 0.52] and 0.95 [SD: 0.40],
maximum distress rating of 3, the respectively; P ⫽ .04). We found no
maximum d is 165. These scores ranged Gender analysis significant difference between the sum of
from 1 to 97 (mean: 46.9 [SD: 21.7]), Whereas the sample sizes were small, we distress ratings for men and for women,
with an approximately normal did find differences between the sexes in but men experienced distress per
distribution. Each student’s frequency measures of frequency and distress. Both situation at a level almost significantly
and distress sums were plotted against male and female students witnessed higher than that experienced by women
each other so that we could examine the nearly every situation included in the (1.46 [SD: 0.42] and 1.23 [SD: 0.51],
relationship between frequency and survey. The mean (SD) sum of frequency respectively; P ⫽ .057).
distress. Figure 1 shows a wide ratings was significantly higher for
distribution of these data, although there women than for men (65.19 [SD: 28.73] Reasons for not taking action
is a generally linear trend (R ⫽ 0.67). and 52.94 [SD: 22.12], respectively; P ⫽ .04). Table 3 shows the reasons that students
Cronbach alpha, in which each “item” is In addition, we found that women chose not to take action in the face of
the product of its frequency and distress, had a significantly higher mean (SD) distressing situations. The most

114 Academic Medicine, Vol. 85, No. 1 / January 2010

 Well-Being of Students

medical students experience moral

distress on a regular basis. The survey we
created for this evaluation allows the
quantifying of both the frequency and the
intensity of episodes of moral distress. By
elucidating the types of situations that
cause distress, the results provided a
description of the clinical learning
environment, which allows us to gauge
how well that environment reflects the
professional values the medical
profession espouses. Although it was not
specifically designed for this purpose, the
survey also provides a tool for measuring
the burden of distress experienced by
individual students.

We set out to assess the frequency at

which medical students encounter
morally questionable situations and the
degree of distress they felt as a result.
Collectively, fourth-year medical students
recalled every one of the situations on the
survey, and, collectively, each situation
induced some degree of distress. On
Figure 1 Relationship between frequency and distress sums depicted as a scatterplot with
corresponding correlation coefficient (R) for a cohort of fourth-year medical students (N ⫽ 64) at
average, nearly half of the situations
Vanderbilt University School of Medicine, March 2007. occurred at least infrequently, and more
than one-third caused mild-to-moderate
distress. Only eight situations did both.
frequently cited reasons were the opportunity for these students to discuss These higher-frequency/high-distress
student’s subordinate role on the medical experiences they found ethically or items seem to be situations in which
team and his or her lack of confidence morally troubling. Their accounts students (1) perceive a direct, negative
regarding a full understanding of the provided strong anecdotal evidence that impact on patient care or (2) witness
situation. students experience what Jameton6 behavior that is directly disrespectful to
described as “moral distress,” the others. In general, it seems that situations
negative emotions that arise when one that pose more immediate potential harm
Discussion knows the morally correct response to a to others, whether by insult or by injury,
The monthly gatherings of third- and situation but cannot take action because cause a greater amount of distress.
fourth-year medical students that we of systemic constraints. The current study
sponsored for seven years provided an provided quantitative evidence that Several of the items that appeared on the
higher-frequency list did not cause even a
mild amount of distress. Most of these
higher-frequency/low-distress situations
Table 3 involved disrespectful remarks about
Reasons (and Their Mean [SD] Frequency) for Not Taking Action in the Face of other care teams or about patients. The
Distressing Situations in 64 Fourth-Year Medical Students, Vanderbilt University
Vanderbilt University School of Medicine’s
School of Medicine, 2007*
Compact for Teachers and Learners of
Frequency: Medicine clearly declares that such
Reason mean (SD) disparaging comments are unacceptable,20
Because I wanted to be perceived as a “team player.” 1.43 (1.03) and our students recognize them as
.........................................................................................................................................................................................................
Because I wanted to preserve my relationship with an attending and/or 1.64 (1.16) unprofessional, but perhaps this behavior
a resident. is so embedded in the culture that it no
.........................................................................................................................................................................................................
Because taking action might have negatively affected my evaluation. 1.67 (1.22) longer induces the negative emotional
.........................................................................................................................................................................................................
Because I did not want to be disrespectful of my attending and/or 1.83 (0.93) response that characterizes moral
resident. distress. It is also possible that the link
.........................................................................................................................................................................................................
Because I felt that my concerns or questions were due to incomplete 2.09 (1.08) between this behavior and its ultimate
knowledge and judgment. negative impact on team morale and
.........................................................................................................................................................................................................
Because I played a subordinate role on the team. 2.16 (1.04) patient care is so indirect that our
students fail to perceive it.
* Respondents used a five-point scale (0 ⫽ never, 1 ⫽ infrequently, 2 ⫽ occasionally, 3 ⫽ frequently, and 4 ⫽
very frequently) to rate the frequency with which each reason accounted for their not taking action in a
distressing situation. The value in the first cell is significantly different from all other values (P ⬍ .05), and the In February 2007, the Liaison Committee
values in the next three cells are significantly different from those in the last two cells (P ⬍ .05). on Medical Education21 adopted a new

Academic Medicine, Vol. 85, No. 1 / January 2010 115

Well-Being of Students
standard stating, “Medical schools must
ensure that the learning environment
for medical students promotes the
development of explicit and appropriate
professional attributes (attitudes,
behaviors, and identity).” In addition, it
stated that schools should “regularly
assess the learning environment and
develop appropriate strategies to enhance
the positive and mitigate the negative
influences.”21 We feel that a survey such
as the one reported here can aid both in
the assessment process and in the crafting
of educational strategies. For example,
five of the eight items that appeared on
both Table 1 and Table 2 describe
inadequacies in our macrosystems or
microsystems of care, including poor
access, inadequate insurance coverage,
language barriers, and fragmentation. As
part of recent curricular revisions in our
medical school, the students now fully
explore the structure of the U.S. health
care system and the impact of the
inequities of that system on the lives of
those at its fringes. Our data suggest
that students still experience distress,
however, when they encounter these
inequities in the bitter circumstances of
real patients who could have fared better,
if not for their lack of access. We in the
medical profession do discuss our moral
obligation to promote the health of all
members of society, but, as Sautz22
suggests, perhaps we need to move
beyond discussion and equip students
with the skills to become forceful change
agents, thereby encouraging them to
mobilize their distress into action. Our
findings also point to the need to supply
medical students with a greater
understanding of the microsystems that
exist within our hospitals and clinics,
so that they might help to solve the
problems caused by fragmentation and
inefficiencies. Finally, the Vanderbilt
Compact for Teachers and Learners of
Medicine clearly outlines professional
expectations,20 but the data from the
current study confirm that infractions
are common. We still have work to do if
we hope to achieve an educational
environment that fully embodies these
professional expectations and allows our
students to speak up (diplomatically)
when they witness lapses. We must also
counteract these infractions by providing
steadfast examples of superb role
models.23
The high calculated Cronbach alpha that
we found supports the use of that scale
116
for assessing individuals and suggests that
responses from students are consistently
different. Our data demonstrated great
variability in the frequency and intensity
of distress episodes reported by
individual students. This variability is
illustrated by the scatterplot, which
suggests that students who more
frequently experience distress episodes
also are more intensely distressed by what
they observe, notwithstanding gender
variability. This finding raises a number
of questions that call for further
investigation: (1) What is the meaning of
these differences? (2) Do they reflect
inherent differences in moral sensitivity?
(3) Are students who experience greater
degrees of moral distress at risk of
burnout and cynicism, as has been
suggested by the nursing literature?
(4) If so, what interventions can be
implemented to address this risk? (5) Are
students with a lower degree of moral
sensitivity callous, insensitive, or jaded,
and, if so, what are the implications for
their capacity for compassionate care? (6)
Do students in the midrange of moral
sensitivity represent a healthy norm, and,
if so, what are the coping skills they have
employed to help them deal with distress?
(7) Does moral distress relate in any way
to the erosion of professional ideals that
is so often cited as a consequence of
medical education?
Limitations
The current study was limited by its
retrospective design that relied on
recalled estimates of both frequency and
intensity. Despite the inaccuracies of
memory, we must assume that the
reported events and the emotions that
accompanied them were real. In addition,
whereas the survey design provided
quantitative evidence that confirmed the
reality of moral distress, it lacked the
richness and nuance of narrative. We
suggest that future explorations of moral
distress employ both qualitative and
quantitative methods. With a response
rate of 60%, we cannot exclude the
possibility of selection bias, although the
widespread distribution of student
responses would argue against this.
Finally, our data were limited to one
cohort in one institution, and thus our
findings may not be generalizable.
Although we strongly suspect that our
institution is not unique in this regard,
we acknowledge that each institution has
its idiosyncrasies. A survey of this nature
might be most valuable in elucidating the
Academic Medicine, Vol. 85, No. 1 / January 2010
hidden curricula of local environments,
without the need for or an attempt at
generalization.
Future directions
We are currently administering this
survey to third-year medical students and
the residents who work with them during
their clerkships. We hope this effort will
determine whether the response to
potentially distressing situations changes
as learners progress through training. In
addition, we plan to include burnout
scales to determine whether high levels of
distress place physicians-in-training at
risk, as was found for nurses.6 –11 The
gender differences we found suggest that
women perceive a greater number of
situations to be distressing but that men
are more distressed per situation
witnessed. We are curious as to whether
these differences will persist with a larger
sample size.
Measurement is a first and necessary step
in creating change, and we are now using
our data toward that end. Our efforts
thus far have primarily been aimed at
raising the awareness of institutional
leadership groups. We have presented
these data to the department chairs
and course directors who sit on our
Undergraduate Medical Education
Executive Committee; the initial response
has been one of concern and support. In
addition, we have been asked to present
these findings to our Clinical Enterprise
Group, a committee of department chairs
and administrators that oversees all
clinical operations at our medical center.
Although cross-institutional awareness is
critically important, interventions may be
more successful at the departmental level,
because accountability is more direct
there, and microcultures may change
more rapidly than larger institutional
cultures. Data from more recent
administrations of the survey will allow
us to present department-specific
information, and we hope that this
information will provide an incentive for
change as well as an accurate baseline
from which to measure the impact of
targeted interventions. In the meantime,
our Department of Surgery has devoted a
grand rounds session to the topic, and
our Department of Emergency Medicine
recently initiated its own study of moral
distress.
When we revised our third-year
curriculum in 2006, we replaced the

voluntary monthly meetings with four
required small-group sessions that occur
during quarterly intersession weeks.
These meetings are led by “master clinical
teachers” (MCTs), skilled clinician–
educators selected and funded by
Vanderbilt University School of Medicine
to serve as the core teaching faculty for
the third and fourth years of medical
school. The MCTs have undergone
faculty development to better understand
the concepts and potential causes of
moral distress. To provide continuity,
each MCT follows the same group of
eight students throughout the year.
Before each session, students must record
short reflections in an electronic learning
portfolio; these reflections are then
reviewed by the MCTs. Students are
given the option of discussing their
reflections during the small-group
session, and most take advantage of this
opportunity. Although students are asked
to write about any memorable or
instructive event—not only those events
that cause distress—MCTs report that a
preponderance of the stories deal with a
few themes: inadequate systems, difficult
communications, and breaches of
professionalism. One of us (K.D.L.)
recently analyzed close to 200 of these
reflections and identified themes that are
very consistent with the items on our
survey.24 Students and MCTs alike
reacted very positively to these sessions
and complained only that the one-hour
sessions did not provide enough time to
address and fully discuss all of the student
concerns. As a result, four more sessions
have been added, so that they now occur
eight times a year, at six-week intervals.
Data have not yet documented the
effectiveness of these sessions, but this
strategy has been championed by others
as a possible means of supporting the
moral growth of learners.25 Finally, our
MCTs value their roles in affirming the
moral instincts of our students and also
recognize a need to help students develop
the skills required to handle morally
distressing situations. On the basis of the
Academic Medicine, Vol. 85, No. 1 / January 2010
input from these sessions, we plan to
create standardized scenarios that
illustrate the most common of the
distressing situations, so that our
students have the chance to practice
responses that are both effective and
morally sound.
Funding/Support: The Vanderbilt University Cal
Turner Program for Moral Leadership in the
Professions provided support for this study, and
C.W. received support from the Vanderbilt
University School of Medicine Medical Scholars
Program.
Other disclosures: The authors had no conflict of
interest.
Ethical approval: The study received exempt
status from the institutional review board of the
Vanderbilt University School of Medicine.
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