Integrity is a Verb
FRASER SMITH, MATD, ND
Integrity is a quality that everyone respects. It makes a fine word in corporate mission statements, and sometimes it’s meant earnestly. Integrity is vital for a medical education institution and for a health care profession. This month’s title sheds the spotlight on integrity in action, the word in deed. Grammatically speaking, integrity is a noun, although it can be stretched into a verb with the word integrate.
When we think about what integrity means for a higher education institution, particularly one for a health profession, academy honesty is one of the most important elements. This is requisite for valid credentialing, and it has a student and faculty dimension.
Cheating on the Rise
Cheating is on the rise in higher education, and this increase accelerated during 2020.1 This takes the form of assignments for purchase (not new, but far easier to shop for online) and cheating on at-home online exams. Sometimes these efforts display a resourcefulness that faculty wish the student had just directed toward studying the material in the first place. The use of remote, computerized proctoring services has grown exponentially. These platforms use the webcam and microphone of the student’s computer to record their actions, the room, the screen, and more. Algorithms built into the software report to the instructor details such as eye movements and finger activity. The Wall Street Journal recently reported on this, including some of the more daring moves that get caught on video, such as pets covered with answer-bearing sticky notes and poorly executed impersonation attempts.1
Academic dishonesty is a serious affair. A student getting to be a licensed doctor by faking his or her way through school is a terrifying thought. And the corrupting effects of cheating can weaken an institution. There is a damaging effect on student morale as well. Those who play by the rules are angered, sickened, and resentful when they hear of, or even hear boasting from, those who are cheating and getting away with it. I’m not certain if fairness is enculturated, genetic, or both, but nobody likes to think that others are gaming the system.
A culture or normalization of cheating in high school and undergraduate education can carry over into professional school. I suspect that this is less of a factor for naturopathic medicine, simply because the people who self-select to go to naturopathic school tend to be intrinsically motivated and have integrity in their lives overall. Nevertheless, as higher education increases in cost, becomes more remote, and economic pressures mount, the transactional nature of the education process can overtake any kind of friendly agreement or shared values with the Academy. In other words, the thinking may be, “I’ll get away with what I can.”
Why Do Students Cheat?
The future of these online proctoring services remains to be seen. But why do students cheat? The obvious answer is “to get ahead.” And this would be accurate. But the causes are worth exploring. Doing so helps with prevention, but it also informs us about what kinds of mindsets, attitudes, and values (or lack thereof) are on the higher education landscape. This impacts our schools to some extent. There is a loyalty to the medicine and a sense of propriety among naturopathic students. I can’t prove it, at least not today, but my guess is that this is less of an issue for naturopathic students than for the higher education milieu in general. But we know that some students do cheat, plagiarize, etc. And all of our schools have policies and procedures in place to address it. So, along the lines of Tolle Causam, it’s valuable to ask why they do it.
Frustration is probably the prevailing theme this year. In the WSJ article, one student states that he just wasn’t learning effectively with so much online instruction, due to the lack of interaction with the teacher. That doesn’t make it right, but given what students are paying for an undergraduate degree these days, an attitude may set in that since they are self-teaching with their laptop from their bedroom, nobody particularly cares one way or the other. That’s not the most mature stance, but it is a reminder, to me, that humans need real human interaction.
Students have a lot riding on their degrees and their investment, and this is true for professional school. Some high-profile cheating episodes at prestigious institutions of higher education this year underscore the fact that when the heat is on, even some of those students with higher GPAs will resort to cheating. Another is the “ad populum” fallacy, or, as they say, “everyone is doing it.” That is part of the corrosive effects of academic dishonesty: that the students who don’t engage in it may be tempted because they see others exerting an (undue) advantage that they themselves don’t have. Stress is another factor, and the pandemic year induced stress about the SARS-CoV-2 itself, economic pressures for families, and a dearth of social interaction for many.
Faculty can play a role in academic dishonesty. A common one is grade inflation.2 The study by Arum and Roska, outlined in their book, Academically Adrift,3 suggested that grade inflation is very common. This has a snowball effect, as students who are used to obtaining a B for minimal effort and an A for a decent effort will protest vociferously if they receive a C. Again, this doesn’t quite capture the super-hardworking naturopathic medicine student; however, our colleges exist within a cultural milieu that encompasses these pressures.
Teaching Methods Matter
The tension between teaching, learning, and testing in a medical school program sometimes leads us to ask, “Are we teaching these students in the correct way?” A former teacher and friend of mine, Dr David Chandross, is an eminent leader in the field of gamification. The use of serious games, often computer-supported or even virtual reality, taps into a strong desire to learn by doing and exploring. A sense of adventure and purpose underscores the gamified curriculum; motivation as well as learning outcomes rise.
We can go in the opposite direction and make the training about multiple-choice examinations and hard-core exam security. But that tug of war has diminishing returns during the formative years of training. When students can learn and show proficiency by creating projects and portfolios, they can focus more on the learning and less on the test. These sorts of activities can certainly be evaluated by the instructor, and it can lead to more feedback for the student if done right.
On the other hand, there is a place for what we call “Summative” evaluations. This is where a “either you know it or you don’t” test or practical exam engages the student. This can introduce a level of honest self-evaluation on the part of the student. Maybe their knowledge was not as deep as they presumed it to be. It can also provide useful data for the faculty and the program leadership. But too much of this kind of evaluation, it strikes me, becomes amotivational, as it swings the educational process back to a transactional nature. The unspoken contract between teacher and student can turn into “You prepare for the test; I’ll teach to the test.” That’s not entirely bad, but in a 4200-hour-plus curriculum, that’s overwhelming. In a context that serves to educate, not merely train, that is a mistake.
Another kind of integrity is aligned with the concept of professional authenticity. This basically means that we are who we say we are and we have the skills we claim to have. In other words, if we say we are medically trained, or are primary care providers, etc, we are making true statements. We might define this in a different way than medical doctors, but there are core elements that clearly classify a person as a primary care provider. One hallmark, for example, is being able to make a diagnosis, or at least a reasonable accurate initial assessment, and formulate a plan for further investigation and referral, without supervision. Our professional associations provide the vital function of educating the public about this, as well as advising their membership on best practices in communication and marketing so as to not damage their own or the profession’s standing.
In practice, naturopathic doctors can exhibit the quality of integrity in many ways. Examples are providing the services agreed upon with the patient; not providing services outside of one’s scope of practice; honesty in billing insurance companies; and honesty and faithfulness in creating patient expectations and in responding to patient needs.
A related layer of integrity has to do with the assurance functions of the profession. The accreditation agencies are an important example. Specifically, the Council on Naturopathic Medical Education sets standards for naturopathic medical education and works with the schools to ensure that they are all in compliance with those standards. Regional accreditation agencies – or, in Canada, provincial quality assurance boards – look at the function of the institutions: Are they meeting their mission, and are they financially sound?
Licensing exams, such as the Naturopathic Physicians Licensing Examination (to take a ubiquitous example), provide the licensing authorities a way to discern if a license applicant does not pose a risk to the public. Anything beyond this step is really outside of the profession and its agencies; government regulators are there to protect the public, not serve the profession.
The profession as a whole could be said to act with integrity when we base our therapies on solid evidence. What that evidence should comprise is a part of the internal discussion of our profession. Should it only be treatments written up in peer-reviewed medical journals, or should it include traditional practices? Given that most of the research about drug treatments is based on selecting specific conditions and treating them with precise doses of pure chemical compounds, does any of the research in the indexed literature about natural therapies even meet that standard? And should it? The profession tries to take the best evidence through a rational process of inquiry, discussion, experience, and judgment and use that as a basis for practice. That could be described as part art and part science, and this is true of many fields, especially those that involve serving people.
It Starts With the Training
In naturopathic medical education, many parts of the curriculum can support this concept and living practice of integrity. A sound scientific foundation is important. The clinical training, where accurate chart notes and obtaining truly informed consent from patients are required, is another.
Rounding back to the concept of academic honesty, this takes on a new light. What we learn in naturopathic medical college is not just the curriculum, but also the “hidden curriculum” of practice, values, and moral lessons. An educational system of cheats will probably not turn out a profession of honorable practitioners. Thus, our naturopathic educators take pains to ensure that the academic standards remain high.
This goes beyond prevention of cheating, although that is important. It also means that the nature and scope of work that naturopathic students perform is appropriate to their work as doctors. It has to be challenging. But challenging as it may be, it ought to also support learning. An imaginary naturopathic program replete with challenging memory tests for extensive medical terminology and grueling physical fitness tests might appear to be a rigorous program, but it is neither very valid nor relevant to an educational process that helps a student mature into an entry-level physician. On the other extreme, a learning-rich environment that always allows students to self-determine how good they are might lack objectivity. It might let students progress through their program, and acquire some knowledge, but not really be able to perform with the skills of an entry-level physician.
There are experiential and more “hands on” ways for students to be evaluated than written tests. Some of these methods, such as the Objective Structured Clinical Exam (OSCE), can be reliable but tend to have a narrow focus. Others, such as mini CEX (a rating scale of various observed clinical tasks, such as history-taking), are quite valid because they are performed by interns on actual patients. But reliability-wise, they lack scale. What can help is when multiple faculty observe and score an intern working with multiple patients. The power of these observations grows as they accumulate in number the patient encounters for any given intern. This is somewhat akin to the supervisor (clinical faculty) conference where the faculty discuss each intern and how they are progressing. Subjective, yes, but meaningful.
Questions of bias arise with more student-centered and observable exams. Some of them, like OSCEs, or ePortfolios, can require a fair amount of faculty time. In upcoming columns here, we will discuss the use of serious games, which can build in formative and summative (either you know it or you don’t) evaluation.
Just as we wouldn’t want a patient to eat just 1 kind of food, we wouldn’t lean too much on any 1 type of evaluation. And just as we wouldn’t use the same treatment approach for patients at all stages of life and all levels of health, we wouldn’t force the same approach on a student in their first 2 months of the naturopathic medical program, versus an intern, versus someone soon to graduate who is ready for some high-stakes exams.
The path forward, it seems, is to have useful, valid, and student-supportive evaluations and examinations that are appropriate to the situation within the naturopathic program. There are times for high-stakes “summative” evaluations with tight exam security. And there are many occasions where other methods that are more ‘formative”4 are better. This preserves and builds integrity. And it avoids discouraging students with a perceived paper (or pixel) “chase” that has little intrinsic meaning to them. Clearly, integrity is based not only on what students are doing, but also on what our schools and their faculty are doing with (not to) the students. Integrity requires action on everyone’s part.
- WSJ Noted. Students Are Cheating More During the Pandemic. May 12, 2021. WSJ Web site. https://www.wsj.com/articles/students-are-cheating-more-during-the-pandemic-11620840447. Accessed May 23, 2021.
- Jaschik S. Grade inflation continues in US colleges. April 4, 2016. Times Higher Education Web site. https://www.timeshighereducation.com/cn/news/grade-inflation-continues-us-colleges. Accessed May 23, 2021.
- Arum R, Roksa J. Academically Adrift: Limited Learning on College Campuses. Chicago, IL: University of Chicago Press; 2010.
- Yale University, Poorvu Center for Teaching and Learning. Formative and Summative Assessments. 2021. Available at: https://poorvucenter.yale.edu/Formative-Summative-Assessments. Accessed May 23, 2021.
Fraser Smith, MATD, ND is Assistant Dean of Naturopathic Medicine and Professor at the National University of Health Sciences (NUHS) in Lombard, IL. Prior to working at NUHS, he served as Dean of Naturopathic Medicine at the Canadian College of Naturopathic Medicine (CCNM) in Toronto, Ontario. Dr. Smith is a licensed naturopathic physician and graduate of CCNM.