“Do No Harm?” Moral Distress Among Medical Students During the Surgical Clerkship

•Medical students experience moral distress during the surgical clerkship.•Medical students experience moral distress differently than other medical roles.•Experiences of moral distress may impact students’ professional identity formation.•Learning opportunities can be designed to address medical student moral distress. Moral distress, reported among healthcare workers across a variety of settings, is associated with negative mental health consequences, burnout, and intention to leave a position. The scant literature exploring medical students’ moral distress does not specifically examine moral distress during the surgical clerkship nor does it characterize the type of moral distress experienced by medical students. Thus, we aimed to explore and characterize medical students' moral distress during the surgical clerkship. This study was conducted at the University of Michigan Medical School evaluating narrative essays written by 3 cohorts of students (2018-19, 2019-20, 2020-21) who completed the surgical clerkship during their third year of medical school. Deductive content analysis was used to evaluate 180 narrative essays for the presence of moral distress using a 5-subcategorization schema developed by Morley et al. (constraint-distress, tension-distress, dilemma-distress, uncertainty-distress, and conflict-distress). Four of the 5 sub-categories of moral distress (constraint-distress, tension-distress, dilemma-distress and uncertainty-distress) were identified in medical student essays. There were no examples of conflict-distress. Medical students described 4 of the 5 sub-types of moral distress during their surgical clerkship. The sub-types of moral distress most often experienced by medical students are different than sub-types of moral distress previously reported among nurses, suggesting the varied roles and responsibilities of the healthcare team impact the scenarios most likely to present moral distress. Additionally, medical students were hesitant to raise concerns with their team when they experienced events discordant with their moral beliefs; they cited their position in the medical hierarchy, fearing implications on their future career, and perceived lack of knowledge and experience as factors limiting their willingness to share. Finally, this study identifies morally distressing scenarios as opportunities for transformative learning for medical students specifically in the realm of professional identity formation.