Sources of Ethical Conflict in Medical Housestaff Training: A Qualitative Study

Julie R. Rosenbaum, Elizabeth H. Bradley, Eric S. Holmboe, Michael H. Farrell, Harlan M. Krumholz

Research output: Contribution to journalArticlepeer-review

50 Scopus citations


Purpose: Despite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers. Methods: We performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues. Results: The interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients' wishes, preventing harm, managing the limits of one's competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training. Conclusions: This study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism.

Original languageEnglish (US)
Pages (from-to)402-407
Number of pages6
JournalAmerican Journal of Medicine
Issue number6
StatePublished - Mar 15 2004
Externally publishedYes

Bibliographical note

Funding Information:
We wish to thank Ann Senick, MSW, for her research assistance, and Nancy Angoff, MD, David Berg, PhD, and Helena Hansen for their comments on the manuscript. We also appreciate the generous support of the Yale University Interdisciplinary Bioethics Project and the Robert Wood Johnson Clinical Scholars Program. Finally, we especially appreciate the housestaff who participated in this study and thank them for their time and candor.


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