To the Editor: Parker and Wilkinson raised the issue of medical students who behave inappropriately.1 It is likely that the major way medical students cause distress to others is through deliberate, inappropriate behaviour, representing a deficiency in empathy, rather than through laziness or other mental or social problems. In identifying the problem in these individuals, we need to consider whether the impairment is to the cognitive aspects of empathy — knowing how to behave — or to the emotional aspects — caring about the feelings of other people.2 Inappropriate behaviour can result from differing degrees of impairment in either of these domains, and different courses of action need to be considered for those at the extremes of either type of impairment.

An extreme lack of the cognitive components of empathy might be seen in those with developmental disabilities, such as autism spectrum disorders. In these cases, intensive tutoring in professional skills and appropriate career guidance can produce competent and sympathetic doctors.3

At the other extreme, a severe deficiency in the emotional aspects of empathy — not caring about other people’s feelings — may be difficult to correct. Individuals with these psychopathic traits are thought to exist at high levels in many organisations.4 They — especially those with Machiavellian and narcissistic tendencies — may alter their behaviour to become competent medical students. However, their true lack of empathy may become apparent when their careers are secure, and they are in positions of real power. At that stage, they might put patient health and the psychological state of their colleagues at much greater risk.

It is likely that some of the most dangerous doctors, such as Harold Shipman in the United Kingdom, represent extreme examples of this pattern. Medical schools need to be certain that any behaviour problems are truly correctable, and consider a thorough personality and cognitive assessment for students who present with inappropriate behaviour, to determine a course of action that will ensure the safety of future patients and colleagues of these students.