Appendix 39b - Cognitive Dissonance

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

In a 1990 AMA pilot study of third year medical students, 100 percent report sleep deprivation - up to 100 hours straight on surgery - and 97% thought it impaired their ability to care for patients. At the same time, however, most agreed with the statement, "Sleep deprivation was worth it because of what I learned."[420]


Quoting from an article in Family Medicine:

Denial in the medical education system is strongly linked to the very human need to believe that a painful experience was 'worth it'.... Complaining about call schedules is acceptable, but admitting to feelings of pain, uncertainty, abandonment, and depression, even to themselves, seems intensely disloyal and threatens their sense of membership in the medical family.[421]

This is an example of the well-known psychological principle cognitive dissonance, the suffering-leading-to-liking hypothesis. 1997 marked the 40th anniversary of the theory characterized as the single most important development in the history of social psychology.[422],[423] Few groups exemplify this phenomenon better than medical students. Change your actions or change your feelings about the consequence - I choose to be here and let myself be treated this way; I must be learning and liking it. To minimize dissonance, medical students must either convince themselves that the "initiation" was not that bad or they can exaggerate the positive characteristics of medical studenthood and minimize its negative aspects.[424]

One of the reasons why the theory is considered so important and provocative is that its predictions are exactly opposite to what one might expect. One would think that the unpleasantness of a brutal initiation would rub off on the group.[425] Counterintuitively, though, it seems the more a person suffers in order to obtain something, the greater will be the tendency for that person to evaluate it positively. And apparently, the more horrific an initiation, the greater its effect. Quoting from an article in Pharos, initiations eventually instill, "an inflated and rationalized estimate of their own worth."[426]

Each act of denial, conscious or unconscious, is an abdication of our power to respond - Joanna Rogers Macy

One prediction of the theory might be that the incidence of harassment and abuse is actually being under-reported. For example, given standardized scenarios - such as an attending physician who consistently describes women medical students and residents as "girls" - medical students perceive less and less harassment as they advance through training. This leads the authors of the survey to suggest that, "Perhaps people 'buy into' certain settings for their own psychic survival and/or to increase the likelihood of their success."[427]

To study perceptions of abuse, clinical situations were drawn up and presented at a medical conference to garner student comments. The author of the study was surprised how far many medical students were willing to let behavior go before they thought it crossed the line into abuse. "There was one vignette where a surgeon physically struck a student on the knuckles with a scalpel during surgery when she made an error in tying a knot," explains one author, a situation they thought occurred quite frequently. Some medical students were hesitant to label this as abuse. One said, "Well, at least he didn't stab her." The author believes this points out how early students become conditioned to accept abusive treatment as, "the way things are."[428]


[420] Sheehan, H, et al. "A Pilot Study of Medical Student 'Abuse.'" JAMA 623(1990):533-537.

[421] McKegney CP. Family Medicine 21(1989):452-457.

[422] American Journal of Psychiatry 111(1955):319.

[423] American Journal of Psychiatry 110(1954):127.

[424] Aronson, E and J Mills. "The Effect of Severity of Initiation on Liking for a Group.":177-181.

[425] Gerard, HB and GC Matthewson. Journal of Experimental Social Psychology 2(1966):278-287.

[426] Reidbord, SP. The Pharos 1983(Summer):2-8.

[427] Nora, LM, et al. "Stress and Harassment." Academic Medicine 68(1993):S49-S51.

[428] Yermon, S. "Drawing the Line on Student Abuse." AAMC Reporter 9(1999):1,6.

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