Have you experienced the groans that echo through the lecture hall when the word “mandatory” appears on a syllabus? If you have spent more than five minutes in medical education, you have experienced the resistance and rebellion of students who are deeply offended that they must physically occupy a space they are paying hundreds of thousands of dollars to be in. Since the introduction of note-taking services, medical students only want to speed up video lectures to 2.5x speed, crush Anki flashcards, and treat campus like an optional drop-in center. A required small group or a mandatory lab isn’t an opportunity—it is an imposition on their study time.

But beneath the righteous indignation lies a massive disconnect about what medical school actually is. Students view it as an information-acquisition race. If they can download the knowledge into their brains via TikTok or YouTube, they feel they are learning based on their particular “learning style”. What students fail to realize—and admittedly we fail to communicate this to them—is that medical school is not a trade school where you simply memorize a manual to pass Step 1. It is an incubator for professional identity formation [1,2]. You do not just wake up on graduation day with the instincts, accountability, and resilience of a physician; you build those traits by showing up when you don’t want to and recognizing that even when you as a student are passive, there are a myriad of opportunities to learn by observation, as behaviors and skills are modeled by the faculty and residents.

When a student skips a small group because they “study better alone,” they miss the entire point of the exercise. The point isn’t the clinical vignette on the paper. The point is learning how to navigate a room full of varying opinions, how to speak up when you are uncertain, how to hold your tongue when a peer irritates you, and how to collaborate under pressure. That is the actual practice of medicine. A computer screen cannot teach you how to manage the awkward silence when a team is stuck on a differential, nor can it teach you the subtle art of reading a colleague’s body language. Every time a student chooses isolation over presence, they stunt the growth of their professional identity, remaining a professional student rather than transitioning into a future colleague.

Worse yet is the attitude toward mandatory clinical placements. The “why do I need to be here if I am not doing anything” complaint is a symptom of a myopic, consumer mindset. Medicine is an apprenticeship, and part of an apprenticeship is learning how to exist in the clinical environment—learning the cadences of the wards, witnessing how senior physicians handle tragedy, and understanding the sheer weight of patient care. When students treat attendance as negotiable, they are being unprofessional. They are implicitly stating that their time is inherently more valuable than the faculty’s, their peers’, and ultimately, the patients’. If you cannot commit to showing up for a scheduled clinic, how can a residency program trust you to show up for a code at three in the morning?

So how do we fix the communication breakdown without just sounding like angry, out of touch curmudgeons? First, we have to stop hiding behind the word “mandatory” without offering a philosophical justification [3,4]. If an activity is required, we need to explicitly state what professional competencies are being taught, modeled, and/or evaluated alongside the medical knowledge. We need to frame attendance not as a bureaucratic box to check, but as a non-negotiable contract with the profession they are trying to join. In addition (and not a popular opinion), we need to hold them accountable for showing up and stop cowering when they protest.

Furthermore, we must ensure our mandatory sessions actually deserve their presence. If we drag students to campus just to read slides to them that they could have read at home, they have every right to be angry [5]. We must design interactive, messy, high-yield sessions where active participation is the only way to succeed. We need to be comfortable with improvisation in the classroom to make it more dynamic (Yes, that means admitting you may not have all the answers). When we treat their time with respect, we earn the right to demand their presence. We need to change the narrative from “you must be here because it is the rule” to “you must be here because this is where you learn how to look, act, and think like a doctor, and because you cannot afford to miss this session.”

What do you think? Here are some questions to consider:

• How much of the student pushback against mandatory attendance is driven by a consumerist “I pay tuition, so I decide how to learn” mindset versus genuine burnout from an overloaded curriculum?
• If we assess professional identity formation as a core competency, should persistent, unexcused absence from interactive sessions be treated as an academic failure rather than just a minor professionalism lapse?
• In what specific ways have we as educators diluted the value of “showing up” by requiring attendance at sessions that could have easily been handled asynchronously?
• How do we balance the flexibility required for modern adult learning principles with the rigid, physical demands of clinical practice and apprenticeship?

References

1. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med. 2014; 89(11):1446-1451. DOI: 10.1097/ACM.0000000000000427
2. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: integrating identity formation into the medical education discourse. Acad Med. 2012; 87(9):1185-1190. DOI: 10.1097/ACM.0b013e3182604968
3. Brown MEL, Coker O, Heybourne A, Finn GM. Exploring the hidden curriculum’s impact on medical students: professionalism, identity formation and the need for transparency. Med Sci Educ. 2020; 30:1107-1121. DOI: 10.1007/s40670-020-01021-z
4. Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles. Med Teach. 2019; 41(6):641-649. DOI: 10.1080/0142159X.2018.1536260
5. Sharpless J, Baldwin N, Cook R, et al. The becoming: students’ reflections on the process of professional identity formation in medical education. Acad Med. 2015; 90(6):713-717. DOI: 10.1097/ACM.0000000000000729

Author: Gary L. Beck Dallaghan, Ph.D., Alliance for Clinical Education