Author’s note: This article was written by Sian Hsiang-Te Tsuei and Amy Po-Yu Tsai.
Pham (2013) questioned medical students’ underlying reason for volunteering to perform physical exams at free clinics and concluded in the article “Volunteering in Medical School: A Waste of Time?” that volunteering will never be a waste of time because medical students matriculate to “improve the quality of life for humankind, to service the underserved and to advocate for our patients who need [doctors] most.”
However, we question the validity of the statement. We draw on volunteer motivation literature to support the idea that altruistic intention is in fact only one of several motivating factors for medical student volunteer work. We then explore an interesting track where cognitive dissonance may have implications in motivating medical students to volunteer, and we end this discussion by calling our colleagues to renew their focus on altruistic values.
To start, Merriam-Webster dictionary defines altruism as “unselfish regard or devotion to the welfare of others; behavior (…) that is not beneficial to or may be harmful to itself but that benefits others.” Starting at a premedical stage, applicants’ volunteer work, research work and academic excellence should be tailored to the goal of the current or future patients’ benefit.
However, Hafferty (2002) showed that medical school applicants may be “well-versed in academic and related (e.g., service activities) requirements, but may not have given much thought to [service-oriented behaviors]” that exemplify altruism. In fact, only one out of the 17 students interviewed believed altruism to be a part of the professional aspect of physicianship. Even after matriculation, medical students’ actions continue to be driven by utilitarian motivations.
Studies of voluntary work have provided at least six motivation factors, and they are summarized in the table below from Clary et al. (1998). We contextualize these volunteer motivation factors in the table using the example of volunteering to perform physical examinations to patients as medical students.
|Volunteering motivation factors||Descriptions of the motivation factors||Motivational factors contextualized with volunteer physical exam|
|Understanding||Volunteering permits one to learn or practice knowledge, skills, and abilities||Performing the physical exam helps to consolidate the physical exam routine|
|Career||Volunteering helps advance one’s career in a utilitarian function||Becoming more familiar with physical exams can help increase efficiency on the wards and impress preceptors|
|Social||Volunteering offers opportunities to be with friends, or undertake activities deemed to be positive||Other students are also volunteering there.Volunteering is seen as altruistic|
|Protective||Volunteering can help alleviate one’s guilt in being more fortunate than others or can help address one’s own problems||Free physical exams can help socioeconomically disadvantaged patients who cannot afford it|
|Enhancement||Volunteering enhances one’s own self-esteem||Volunteering helps students feel needed|
|Values||The behaviour of volunteering or the behaviours carried out in the respective volunteering activities allows one to express and attain one’s values||Caring for others is important and volunteering is a way to show caring|
We propose that all factors, except values, are in fact slanted with personal gain.
Factors (1) understanding and (2) career refer to improving volunteers’ understanding of learned subjects and improving career prospects through volunteer activities, which are self-serving. Providing physical exams was asserted by Switzer et al. (1999) as an example of this motivation, where students take the volunteer session as an opportunity to improve their techniques and subsequently enhance their career prospects. The likelihood of volunteers providing services for career reasons was elucidated in a study on Junior League volunteers by Jenner (1982), where 15% of the volunteers perceived that the experience helps them prepare for a new career or maintain career-specific skills, which offers clear benefit for volunteers.
Factor (3) social refers to volunteering activity as an expression of a favorable activity viewed in social circles, which can also improve one’s reputation or provide social activities among friends. Aiming to enhance social status through volunteerism qualifies this as a self-serving motive.
Factor (4) protective refers to the possibility that volunteering can serve an emotionally protective or cathartic function for individuals to cleanse their guilt for being more fortunate than others. It is self-serving for the fact that the volunteer undertakes the activity to brighten their emotions.
Factor (5) enhancement focuses on how volunteers can enhance their own self esteem or raise their mood by feeling needed and therefore valuable. The aim is to improve the sense of self-worth through helping others, and qualifies again as self-serving.
We would like to explore the last factor, values, more deeply. The first facet of altruistic value is more straightforward. Individuals who value altruism naturally perform services for others, acting purely for others’ gain without ulterior motives. We describe this as “expressing values,” and we believe that this may in fact be the only true altruistic motivation.
The second more counter-intuitive facet is “attaining values,” where volunteers hope that by acting in an altruistic way, their actions may feedback cognitively to alter their values to become more altruistic. For example, students may be taught that altruism is a virtue, and in hopes of exemplifying such an attitude, may begin volunteering at underserved areas. The cognitive dissonance between the held belief and the actions may subsequently lead to modified beliefs in order to justify the actions to be reflective of one’s actions. Such actions would have needed to produce enough cognitive dissonance to disturb and shift the original cognitive equilibrium, i.e. the original state where the individual did not perceive altruism as his or her own intrinsic value, as described by Harmon-Jones and Harmon-Jones (2007). Volunteering therefore serves the volunteer’s interest as an exercise to help the volunteer develop the desired trait. While rare, some medical students have indeed expressed this as a motivating factor. As far as we know, there has been no research pointing to cognitive dissonance as a motivating factor for volunteer work.
What has been shown thus far in this discussion is the disheartening result that although altruism may play a part in motivating volunteerism, it is merely one of the various factors motivating volunteer work. Most of the motivating factors may in fact be fueled by gains for the medical student, and this is all the more likely, given that medical students rarely factor altruistic behaviors into their considerations of what constitutes professional behaviors.
The result is disheartening because altruism has been upheld as a goal and a responsibility for medical doctors since Hippocratic times as argued by Cruess et al. (2002). The profession of medicine is defined by its unequivocal duty to help those in need even when it is past working hours without care for personal gain. Doctors are supposed to go above and beyond the call of duty for the sake of the patient. They are supposed to hold their hospital posts to cure patients with SARS despite possible self-contamination.
The CanMEDS Physician Competency Framework, developed by The Royal College of Physicians and Surgeons of Canada, is built around producing medical professionals who are socially responsible individuals proficient in academics and motivating social change. Indeed, medical doctors have been proposed by Farmer et al. (2006) as a force to combat the structural inequity on the socioeconomically disadvantaged castes of the globe, and it is in this spirit that we urge our fellow colleagues to uphold the virtue of altruism that has been handed to us by forefathers of this profession. It is an honor and privilege to care for the ill and advocate for the weak, and it is up to our generation to propagate such virtues through our thoughts, words and actions.