Volume 8, Issue 4 - April 2025

Dear Yvonne,

In this issue of The Academy, we take up a practice of professionalism that most often arises in contexts of challenge: whistleblowing. In light of the norms – both ethical and otherwise – that help to delineate (groups of) health practitioners as members of health professions, those exhibiting professionalism can find themselves in challenging situations when they notice professional lapses in others, culture that do not support professionalism, and structural features of the healthcare landscapes of socio-political contexts which push against the realization of their professional norms. In facing such situations, professionals may discern that in order to stay true to their calling, to satisfy their professional obligations, or merely “to do the right thing” requires that they stand up and report what they have witnessed. However, so standing may run afoul of other codes of conduct – articulated or implied – both internal and external to the club that can be professions. As Jill Thistlethwaite recalls, in the opening sentences of the first article in this issue, there is a code even children understand about not sharing information with authorities. What are professionals to do? Thistlethwaite laments that whistleblowing is still necessary, highlighting the relevant features of It both from philosophical and interprofessional educational perspectives. Were institutional governance stronger, so the story goes, blowing the whistle may not be necessary. C’est la vie. Her article concludes with a reference to Carl Elliot’s recent book,[1] which will leave readers with little hope for the human condition as Elliott traverses the globe from one devastating research ethics violation to another.[2] This helps to make sense of the title of Thistlethwaite’s piece, a question which the lives Elliott portrays give one answer to, but which our send and third articles offer another.

The second article in this issue, authored by Zavia King, highlights a less focused on perspective in the context of whistleblowing and healthcare professionalism: the role of experienced medical students. King situates the relevant ethical and professionalism considerations of whistleblowing well within a self-reflective and open narrative illustrating the divergent paths that professionals – and institutional structures – can take when it comes time to (potentially) blow a whistle. The costs of the lingering questions when a professional does not stand up might, unfortunately, need to be balanced against that “career death wish” that Thistlethwaite asks after.

The third article, authored by Nick Kieran, expands the set of professionally acceptable responses to situations which call out for the aforementioned standing up. It should be noted that such situations rage in severity from small and common yet unprofessional behaviors to the grave violations of human dignity of which Elliott writes. As King highlighted, among others, a case of a positive response to standing up, Kieran highlights how going the extra mile – without calling out others – is both viable and professionally important.

As a collective, these articles shed light on an important phenomenon that could benefit from further reflection by those working in the professionalism space. The reader should leave, after engaging the work of this issue, with a simple moral, like always stand up. Each professional must decide for themselves what is needed to stay true to the norms of their health profession. Upholding the norms of professionalism in the face of obstacles is not easy; in some cases, it calls for additional care to be taken, time to be spent; in other cases, it requires standing up and pushing back on routine a culturally accepted practices on a service or in a hospital; and, sometimes, in context of significant challenge, when structural features are morphed in such a way to conflict with essential features of professional practice, whistleblowing by a profession, as a whole, may be required.

The usual announcements and highlights of relevant and interesting professionalism-related work accompany these three thought-provoking articles. Pay special attention to the upcoming conference, which promises to be both enjoyable and professionally enriching – for in person, as well as virtual attendees.

Bryan Pilkington, PhD, Professor of Bioethics, Department of Medical Sciences, Hackensack Meridian School of Medicine, Editor-in-Chief of The Academy

References:

[1] Elliott, Carl. The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No. First edition. New York, NY: W.W. Norton & Company, 2024.

[2] To hear Elliott discuss whistleblowing, check out this conversation with him: https://www.spreaker.com/episode/the-occasional-human-sacrifice-a-conversation-with-carl-elliott--60778841

1. APHC Hybrid Conference - Building and Rebuilding Trust | June 4-6, 2025

2. Whistleblowing: A Professional Responsibility or a Career Death Wish? 
3. The Importance of Basic Respect for Upholding Professionalism in Medicine: Can Medical Students Blow the Whistle?
4. Pursuing Professionalism Through Empathy
5. Health Ethics Podcast - Neurodiversity
6. Healthcare Professionalism: Education, Research & Resources Podcast
7. APHC Member Benefits

Registration Now Open

The Academy for Professionalism in Health Care is an inclusive organization which welcomes all professionals and their trainees who are devoted to the study and advancement of professionalism in health-related fields. The hybrid international conference will take place in-person at Rosalind Franklin University of Science and Medicine (North Chicago, Illinois, USA) and virtually using Zoom. The conference will include 3 Keynote Presentations, 3 Symposia, 1 Fireside Chat, 15 How-to Workshops, 3 Problem-solving Sessions, 6 Panels, 28 Oral and 8 Flash Presentations. All sessions are hybrid and will be recorded for future viewing.

There will be ample opportunities to network with colleagues. Over 60 sessions will cover topics such as:

• Rebuilding Trust after Professionalism Lapses (Pre-conference Workshop)
• Theoretical Concepts & Frameworks
• Patient Trust – Difficult to Gain, Easy to Lose
• Trust Threats in Multicultural Learning Environments
• Entrustable Professional Activities (EPAs)
• Trust Building within Interprofessional Teams
• Trust in Research & Processes of Protection (e.g., IRB)
• How Trustworthy is Technology (e.g., AI)

Click HERE to register.

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Growing up in England I remember well the unwritten children’s code of conduct that telling tales to a person of authority was unacceptable.  Such behaviour could result in peer ostracism and reprisals.

There are many synonyms of ‘telling tales’ in English: snitching, shopping and in Australia dobbing in.  The grown-up version is whistleblowing: ‘the disclosure by a person, usually an employee, to the public or to the authorities, of negligence, cover‐ups, mismanagement, corruption, illegality, bullying and malpractice at their workplace…also referred to as disclosure in the public interest’.[i] The United Kingdom’s General Medical Council’s policy distinguishes whistleblowing concerns from grievances. Whistleblowing relates to actions with potential threats to the public; a grievance is a private complaint such as between employee and employer, with no public interest.[ii]

Whistleblowing in healthcare typically relates to the identification and reporting of professional misconduct including patient safety issues and lack of provision of optimal care.  One would think such action is praiseworthy and a professional responsibility. Indeed, while not necessarily referring to whistleblowing as such, medical professional standards and ethical codes of conduct, including the American Medical Association’s,[iii] see such reporting as an ethical and professional responsibility. Yet, similarly to those playground consequences, whistleblowers are frequently maltreated, suspended and placed at risk of career suicide, even though their actions may have positive outcomes.[iv]

A prime example of such treatment was the 1990s Bristol heart scandal that introduced me to whistleblowing when I was working as a family doctor in the UK.  Babies at the Bristol Royal Infirmary were dying at an unexpectedly high rate following cardiac surgery.  An anaesthetist, Stephen Bolsin blew the whistle. A subsequent public inquiry reported on the lack of leadership, a lax approach to safety and an old boy’s culture among other root causes.[v] Of interest to me as an advocate for interprofessional education was the finding of failings relating to poor communication between health professionals and dysfunctional teamwork. However, while vindicated, Dr Bolsin could not get another job in the UK and subsequently emigrated to Australia.[vi]

Acknowledging the potential negative consequences, ethicists and political philosophers Kumar and Santoro[vii] argue that whistleblowing is morally justified when the expected risk of harm to the whistleblower is higher than any potential advantage gained from the act (ie there is minimal self-interest). In addition, the disclosure must be backed up by evidence and be in the public interest, though how this is decided may be complicated.

Many institutions do have facilitatory whistleblowing policies including information on how to report and to whom.  Online courses are frequently mandatory on joining an organisation, but their message can be lost in the morass of other health and safety modules.  Moreover, such advice may be difficult to put into practice, particularly for less experienced health professionals overwhelmed by the traditional medical hierarchy.   Residents and medical students, for example, may be deflected from officially reporting concerns if a senior clinician suggests that action should be kept within the profession, and could be dealt with by a quiet word to a colleague. While cup of coffee conversations[viii] may be suitable for discussing poor professional behaviour with an individual, escalation to a formal process is required for persistent poor practice affecting patient care and outcomes. Yet, going outside the medical profession may be viewed as disloyalty to one’s in-group and an affront to the historical right of a profession to self-regulation.

Strategies that healthcare organisations employ to deflect whistleblowing include discrediting, belittling or threatening the whistleblower, delaying action until the person changes job, suggesting that patient care will suffer if an inquiry takes place, or simply ignoring the complaint.[ix]  In addition, organisational factors that inhibit whistleblowing (either intentionally or unintentionally) are hard-to-access reporting mechanisms such as an online portal, toxic leadership and a hostile workplace culture. According to recommendations from an integrative literature review, organisations should therefore develop and implement transparent structures and polices to reward internal reporting and protect the whistleblower.  Core organisational values must be ethical with leaders actively role modelling integrity.[x]

Sadly, whistleblowing continues to be necessary while much institutional governance remains suboptimal.  Yet, as Richard Smith (emeritus editor of the British Medical Journal), in a review of Carl Elliott’s book on whistleblowing,[xi] reminds us that ‘most of us don’t blow the whistle because we recognise where the power lies’, and that whistleblowing is likely to affect your whole life.[xii]

Jill E Thistlethwaite, BSc MBBS PhD MMEd FRCGP FRACGP, Adjunct Professor Faculty of Health, University of Technology Sydney, Sydney NSW, Honorary Professor School of Nursing and Midwifery, Western Sydney University

References:

[i] Gov.uk. Whistleblowing for employees. Available at:  www.gov.uk/whistleblowing/overview

[ii] General Medical Council.  GMC policy on whistleblowing, 2018.  Available at: https://www.gmc-uk.org/-/media/documents/DC5900_Whistleblowing_guidance.pdf_57107304.pdf

[iii] American Medical Association.  Code of medical ethics.  Available at: https://www.ama-assn.org/topics/ama-code-medical-ethics

[iv] Lim C, Zhang M, Hussain SF, Ho RCM.  The consequences of whistle-blowing: an integrative review.  J of Patient Safety 2017; 17(6): e497-e502. 10.1097/PTS.0000000000000396

[v] The Bristol Royal Inquiry report. Available at: http://www.bristol-inquiry.org.uk/final_report/report/Summary.htm

[vi] Dyer C. Whistleblower in Bristol case says funding was put before patients.  BMJ 1999; 319, https://doi.org/10.1136/bmj.319.7222.1387a

[vii] Kumar, M., & Santoro, D. (2017). A justification of whistleblowing. Philosophy & Social Criticism 2017; 43(7): 669-684. https://doi-org.ezproxy.lib.uts.edu.au/10.1177/0191453717708469

[viii] Hickson GB, Pichert JW, Webb LE, Gabbe SG.  A complementary approach to promoting professionalism: identifying, measuring and addressing unprofessional behaviors.  Acad Med 2007; 82(11): 1040-1048. 10.1097/ACM.0b013e31815761ee

[ix] Coull R. Blowing the whistle.  BMJ 2004; 328, https://doi.org/10.1136/sbmj.040264

[x] Augustine L.  Whistleblowing in healthcare for patient safety: an integrative literature review.  Int J Human Research Studies 2022; 12(1): 15, 10.5296/ijhrs.v12i1.19477

[xi] Elliott C. The occasional human sacrifice: medical experimentation and the price of saying no. New York: Norton & Company, 2024.

[xii] Smith R. Deep and fascinating insights into whistleblowing.  BMJ 2024; 385, 10.1136/bmj.q1147

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Medical students play a vital role in patient care within clinical teams, yet they often face significant challenges regarding professional recognition and respect. In many environments, respect is inherent or cultivated, but hierarchical structures in medical training can undermine students' sense of value and inclusion. This situation can be especially challenging for nontraditional students, who often bring valuable prior experience to their education. Despite being called medical students, many feel like glorified shadowers—present but often unheard.

It is imperative to consider how these dynamics impact not just student learning but also professional growth and patient care. When medical students feel respected by faculty and peers, they are more engaged and confident. This enhanced engagement fosters their development and enables them to contribute meaningfully to their teams. Students in a supportive environment are more likely to share insights and innovative ideas, leading to improved collaboration and better patient outcomes. They are also more willing to identify and address challenges, embracing a culture of learning rather than one of fear.

The concept of whistleblowing, where individuals disclose information about illegal or unsafe practices, becomes pertinent here. When medical students feel secure and respected, they are more inclined to whistle blow when necessary, enhancing patient safety and overall care quality. In contrast, a lack of respect can discourage students from reporting issues due to fears of backlash for challenging established norms.

During a clinical rotation, I observed a patient with asymmetric arms. The significantly larger arm was edematous from the upper bicep to the fingers. The patient reported no pain or trauma and was otherwise recovering well, scheduled for discharge that day. Concerned about a complex deep vein thrombosis, I felt it was crucial to share my findings with the medical team.

In a previous career as a patient care associate, I worked on the stroke floor which had a reputation for being overworked and understaffed. I had a stroke patient who was planned to be discharged later that day and developed a new fever. I had no prior experience with the hierarchy of medicine and immediately informed my nurse and the nurse assistant manager. This of course caused a delay in their discharge and indirectly left me feeling punished by the team for being diligent. I was monitored more and denied overtime even when the floor needed it. Given this history, I was nervous about discussing the patient's arm asymmetry and its potential impact on my evaluation. However, prioritizing the patient’s well-being over my concerns, I presented my findings to the attending physician. To my surprise, the team welcomed my concern and used it as a teaching opportunity about superficial venous thrombosis. We decided on conservative treatment and further monitoring, during which the patient's condition improved. Fortunately, the team turned what could have been a negative experience into a valuable lesson, reinforcing the importance of open communication in medical education.

During another clinical rotation, I observed a senior resident fail to perform an abdominal exam on a patient while documenting normal findings. Although the patient had no complaints, I noticed a troubling pattern; whenever this resident conducted a physical exam, she rushed through the process and was commended by her attendings for her “efficiency.” I wanted to discuss this with a team member but hesitated, knowing this resident had a “stern” reputation and was closely allied with another attending known for similar behavior. Previously I requested evaluations from these two and received scores that I felt were unfair and did not match evaluations I had ever received before. Because of these factors, I chose to remain silent and be seen and not heard when working with those providers. Yet, I often contemplate how many opportunities for crucial insights was lost and whether I fulfilled my duty to the patients in our care or prioritized political relationships and my grade over their well-being. Should I have blown the whistle?

A supportive learning environment fosters collaboration, improves patient safety, and prepares future physicians. It encourages open dialogue, values diverse perspectives, and helps students grow by recognizing both their own contributions and their supervisors’ expertise. Respect, mentorship, constructive feedback, and student involvement in decision-making all strengthen this culture. Training faculty to value diversity and understand nontraditional student experiences further enriches the learning space.

Acknowledging respect in the medical training environment is crucial for developing competent physicians who demonstrate professionalism, ethical practices, and leadership skills. When students feel valued and included, they thrive, ultimately enhancing the quality of care provided to patients. By promoting a culture rooted in respect and inclusion, we can prepare the next generation of healthcare professionals to confront modern medical challenges with confidence and integrity, leading to stronger healthcare teams and improved patient outcomes.

Zavia King, Master of Science, Hackensack Meridian School of Medicine, Medical Student.

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As I walked into Lankenau hospital in the pre-dawn darkness that would soon become so familiar, I imagined what my surgery rotation would entail: high-stress situations, observing technical precision, and developing a deeper understanding of anatomy. What I did not anticipate learning was how professionalism is invariably tied to the ability to form meaningful human connections, and how this aspect of care is integral to patient healing.

As I had expected, in my first week I witnessed many of the immense pressures placed on attendings and residents. They triaged critical cases, managed emergencies on the floor and in ORs, and truly worked tirelessly to provide the best care possible. Despite their dedication, I observed a moment that highlighted a gap in professional patient care that left a lasting impression.

I was part of the 8-person team rounding on a large list of patients, and I quickly understood the questions that mattered most to the surgeons. Stool, urination, walking, and current pain were the topics of interest. For some patients, it was as simple as walking into the room, asking those four questions, pressing on the patient’s belly, and moving on. Some patients were happy with this – they were able to return to their primary job of resting and healing with minimal interruption. Some, including Ms. B, were not.

The team entered Ms. B’s room, formed a semi-circle around her bed, and stood intimidatingly above her as one resident began to palpate her abdomen while another asked her the standard questions. She was evidently in pain but was able to answer the four questions. The team turned to exit, already starting to talk about the next patient. Before they could leave, Ms. B began to ask a series of questions. When would she be going home? What could she do to expedite her recovery? Would she need any surgeries in the future? How long would she need to rely on pain medications? Though the team acknowledged her concerns, they offered vague responses, citing the unpredictability of her recovery. Even as they said this, they continued to take progressive steps towards the door, clearly indicating their desire to move on to the next patient. As we left, I glanced back to see her frustration: her need for understanding and compassion had been left unmet.

The next day, the pattern repeated. The residents asked their routine questions – had she pooped, peed, walked, and what her pain level was – and prepared to leave. But Ms. B, still desperate for clarity, pushed back, harder this time. Her frustration boiled over into anger. She accused the team of not caring. Though they apologized, the residents left visibly annoyed, exchanging eyerolls as they moved on.

I couldn’t shake the discomfort I felt. The team wasn’t negligent. They were thorough in checking for complications. But the demands of their job left little room for the emotional needs of patients. I knew that as a student, I had the advantage of time that the residents and attendings lacked. So, I returned to that patient’s room later in the day. She recognized me as the quiet student lingering at the back of our morning group and let me in. I explained my role – not as someone who could fix her medical issues or even answer all her medical questions, but as someone who could listen. After just a few minutes of talking cordially and building a connection, she vented, she cried, and she shared her fears. Simply being heard brought her some relief, and seeing her relief reshaped my understanding of my role as a future physician. I realized that professionalism in medicine involves taking responsibility for a patient’s holistic well-being, acknowledging physicians’ limitations as healers, and admitting when one doesn’t know the answer to a question. As I continue my training, I will prioritize both clinical excellence and fostering trust and open communication with my patients.

This experience underscored key tenets of professionalism, including empathy, advocacy, and patient-centered communication. Professionalism in medicine requires diagnostic capabilities, but it also requires recognizing and addressing the emotional needs of patients. Residency will be demanding, and though I know that it will be difficult to carve out time to build this necessary relationship with patients, I will strive to spend at least a valuable few minutes building a connection with patients that will enable them to feel cared for both physically and emotionally.

Working with Ms. B solidified my commitment to blending medical expertise with human connection, ensuring patients receive the professional care that they deserve. I’m excited to bring this important aspect of medicine forward with me as I begin my career as a physician.

Nicholas W. Kieran, BS, MS, Fourth year medical student at Thomas Jefferson University, Medical Student

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The latest episode of the Health Ethics Podcast is out. 

Check out Neurodiversity: What it is and What Happens Now, a conversation with Drs. Nanette Elster and Kayhan Parsi.

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Professional Formation and APHC collaborate on a podcast, Healthcare Professionalism: Education, Research & Resources.

Over 125 podcast episodes have been released with over 17,000 downloads.

Released every other Saturday morning, recent episodes include Rachel Pittmann discussing Telehealth Etiquette and Amal Khidir talking about Designing the Faculty Development Professionalism Program with Multi-cultural Perspectives.

You can access the podcast episodes on your favorite platform or at: https://bit.ly/PF-APHC-Podcast

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As a member, you have access to special benefits that include:

• Belonging to a community of like-minded professionals
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  Roundtables with authors, faculty, and researchers, plus accessing past recordings
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Our annual membership fees are very inexpensive and are valid for one year from the payment date. Select from seven types of membership, including the institutional membership for four people. See the descriptions.

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Editor-in-Chief: Bryan Pilkington | Managing Editor: Yvonne Kriss

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