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Year : 2011  |  Volume : 24  |  Issue : 1  |  Page : 659

In the News! An Opinion - Bad Apples or Bad Basket?

Associate Editor, Education for Health, The Netherlands

Date of Submission19-Apr-2011
Date of Web Publication29-Apr-2011

Correspondence Address:
J van Dalen
Maastricht University, Skillslab FHML, PO Box 616, 6200 MD Maastricht
The Netherlands
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Source of Support: None, Conflict of Interest: None

PMID: 21710428

How to cite this article:
van Dalen J. In the News! An Opinion - Bad Apples or Bad Basket?. Educ Health 2011;24:659

How to cite this URL:
van Dalen J. In the News! An Opinion - Bad Apples or Bad Basket?. Educ Health [serial online] 2011 [cited 2022 Jan 20];24:659. Available from:

Innovative education relies heavily on collaborative learning, where students are expected to work together in small groups. Collaborative learning has been shown to flourish with learners from a variety of backgrounds. When their mutual prior knowledge is activated, this facilitates the storage of new knowledge. Consequently, much depends on the quality of the collaboration between learners. It is encouraging that much research has been conducted in clarifying the processes that influence this quality.

Attention to the ‘professional behavior’ aspects of medical education has increased since first publications on this topic some 15 years ago. Professional behavior is inherently expressed and measured in interaction with others. Quite often the importance of professional behavior (and its predecessor: the doctor’s and student’s ‘attitude’) is demonstrated through illustrations of unprofessional behavior. People showing unprofessional behavior are usually referred to as ‘bad apples’, suggesting that they can spoil the whole basket of otherwise good apples.

Recently I read a book that I found both fascinating and frightening in this respect. Philip Zimbardo, the author, is professor emeritus of psychology at Stanford University in the USA. He is the author of standard textbooks in psychology and has been the president of the American Psychological Association. He is best known, however, for having conducted and reported about the Stanford Prison Experiment. In August 1971, students were recruited for an experiment looking into the sociological effects of prison life. The participants were paid $15 per day and were free to leave ‘prison’ whenever they wanted. Initially, 18 students were selected, who were then randomly allocated either the ‘prisoner’ or ‘guard’ role.

The experiment was scheduled to last two weeks, but it was ended after only six days. The guards tortured the prisoners; and although the prisoners protested, the emerging social ‘system’ was not changed. Most interestingly, it took a visitor from outside the context of the experiment, who, when confronted with what went on said: "It's terrible what you are doing to these boys!" to get Zimbardo himself, the experiment leader, to recognize the nature of the situation. This outsider was the only one of fifty some visitors to comment in such a way that the experiment leader finally realized the frightening details of what was going on in the experiment. Not only had the ‘guards’ and the ‘prisoners’ identified with their roles, but apparently so had the experiment leader.

Many events in this experiment turned out to be counter-intuitive: Healthy, ordinary students, who were randomly allocated a role, identified with that role within days, to the extent that the ‘guards’ spontaneously developed and used sadistic measures to control the ‘prisoners’. The ‘prisoners’ did protest but lost, and settled into their dependent roles. All participants could leave but only two did, and unwillingly. You can consult for the many - fascinating yet gruesome - details.

Zimbardo has carefully and systematically reported the lessons from this experiment, which has become one of the ‘classic’ experiments in obedience, along with his classmate Milgram’s shock experiment1 and Asch’s conformity studies2. Zimbardo did not hide his own questionable role of over-identifying with his experiment, so much that it got out of hand. More than two decades later, he wrote an in-depth report of the study and a thorough analysis of the findings: the Lucifer Effect3. It took him two painful years to write this book, which is instructive for anybody who is interested in how people influence each other. Zimbardo considers his findings and their relevance to society today, including the last decade’s events in the Abu Ghraib and Guantanamo Bay prisons.

I do not in the least intend to compare health professions education to what goes on in these prisons. I was, however, struck with how much our teaching circumstances resemble critical characteristics in Milgram’s, Asch’s and Zimbardo’s experiments. In health professions’ education we can see a contractual obligation, in which participants have a meaningful role to play. There are basic rules to be followed that seem to make sense before put into action but can then be used arbitrarily and impersonally to justify compliance. Compare the way the white coat is worn or not in different wards. Semantics are used to replace unpleasant reality with desirable rhetoric: ‘verbal abuse’ becomes ‘teaching’ or ‘preparing students to cope with stress’. Responsibility is diffused, and sometimes responsibility for negative outcomes is abdicated. The ‘exit costs’ are high, and an ideology is offered to justify the means to achieve the desirable goal4.

The analyses of these experiments made me realize two things: 1) How little do we know about applying the fairly common lessons from social psychology to the everyday classroom, and 2) Findings from such studies question many assumptions we make in our daily work. We assume that our students are ‘old enough’ to speak out if they are challenged to a debate. We assume that our students are not inhibited when engaging in a discussion among peers. We assume that our students learn to cope with the inherent insecurity resulting from student-centered learning systems, like problem-based learning.

If one message stands out in Zimbardo’s work, it is the overestimation of the freedom of the individual and the underestimation of the influence of the system or circumstances.

There are many examples in health professions education where we overestimate the freedom of individuals and underestimate the power of the system, for example the hospital ward. Looking only at the surface, both Zimbardo’s ‘prisoners’ and our clerks wear white uniforms. Zimbardo’s ‘prisoners’ did not have names but numbers. How many of your clerks do you know by name? Who of us cannot recall inquiring about our professors’ idiosyncrasies or dress codes when preparing for our oral exams?

Studies from the adjacent fields of social psychology are required reading for every teacher and course organizer. They contain messages that we cannot afford to miss when we design our teaching. We must look at the basket, rather than isolate the apples.

Jan van Dalen

Associate Editor Education for Health


1. Milgram S. Obedience to authority. New York: Harper & Row; 1974.

2. Asch SE. Studies of independence and conformity: A minority of one against a unanimous majority. Psychological monographs. 1951;70:whole nr 416.

3. Zimbardo P. The Lucifer effect. How good people turn evil. London: Ryder; 2007.

4. Blass T. Obedience to authority: Current perspectives on the Milgram paradigm. Mahwah NJ: Erlbaum; 1999.


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