By Trevor T. W. Wan and Wai Tak Victor Li

In Hong Kong, an internship, also called housemanship, is a 12-month period during which fresh medical graduates rotate across four departments in public hospitals and acquire hands-on clinical experience through daily care of patients. Yet this phase is fraught with inherent tension: interns, with relatively limited clinical experience, are held to the same, exacting standards of competence that bind fully licensed practitioners. High-profile intern mishaps over the years have brought this tension into sharp relief, including cases of mispositioned nasogastric feeding tubes being missed on X-rays that led to catastrophic feeding into the respiratory tract and subsequent aspiration pneumonia, errors in pre-transfusion blood cross-matching procedures, and delays in diagnosing acute myocardial infarction. These cases, which have elicited considerable public scrutiny and comment, most recently from the city’s health minister, reveal deeper systemic concerns regarding accountability, patient safety, and professional responsibility.

In examining these issues, we find that a Confucian virtue ethics approach is appropriate and helpful. In contrast to deontological or consequentialist theories, Confucian theory focuses on the actualisation of embodied virtue (de) through a lifetime of moral excellence. Core virtues, according to this ancient East Asian philosophical tradition, are humaneness (ren), righteousness (yi), propriety (li), practical wisdom (zhi), and trustworthiness (xin). Education, self-reflection, leading by example, and interpersonal relationships, particularly the hierarchical yet mutually respectful teacher-student or doctor-patient relationship, are all conducive to moral development. As applied to medical training and education, this paradigm emphasises not only adherence to established standards of behaviour, but also the development of virtuous ones.

Interns are in a liminal position. They are still in the process of becoming physicians, yet they already have real responsibility for patients. The fact that many of these mishaps are preventable suggests their repetition is troubling and that the system, as it exists, might sometimes put interns in a situation where doing right (patient safety) conflicts with their stage of development, and thus detracts from rather than enhances professional and moral growth.

Humaneness, sometimes called benevolence, is the fundamental virtue of caring for others. From a Confucian standpoint, the clinical mistakes committed by interns indicate shortcomings not only in technical skills acquisition, but also in virtue and the institutional background needed for the cultivation of humane care for patients. If an intern misses a mispositioned feeding tube or fails to make an accurate diagnosis in time, patient harm results from a temporary deficiency in this kind of benevolent watchfulness.

The cultivation of practical wisdom is especially fragile during the internship. Interns often confront an unrelenting workload that is both physically and mentally taxing. Prolonged shifts, frequent overnight calls, and simultaneous demands of clinical care and administrative burden often leave little time for reflective consolidation of experience, something that Confucians would not hesitate to acknowledge as indispensable in translating raw exposure to actual understanding. Studies indicate that approximately 35% of interns in Hong Kong exhibit symptoms of anxiety, depression, and stress. This burnout heightens the risk of committing clinical judgement errors, suggesting that weariness suppresses the calm judgement inherent in practical wisdom.

The cultivation of mutual trust between supervisors and interns is undermined by a lack of, and sometimes inconsistent, feedback. Without supervisors giving them solid, case-specific advice, interns cannot count on constructive correction of their mistakes and may suffer from unwarranted blame. This erodes the trust that should characterise the teacher-student relationship and discourages interns from seeking help, especially in unfamiliar clinical terrain.

Virtues can only be developed in a conducive social environment and through propriety. This balance is upset by the marked variation in the quality of training between departments, hospitals, and specialties. As a result of different work cultures, patient demographics, mentorship methods, and instructional standards, interns are not subject to systematic moral and bioethical training that the Confucian tradition holds dear. This also conflicts with teaching by modelling (jiao), which, in Mencius’s view, was considered an important means of moral education. When supervisors give only occasional, perfunctory notes, they fail to live up to the ideal of the sage-teacher who models virtue and gently guides students along their path to moral enlightenment. A lack of structured teaching on ethical dilemmas, such as end-of-life choices, resuscitation decisions, and patient communications, leaves interns struggling to develop moral wisdom through piecemeal advice. These render the internship a less-than-ideal site for moral self-cultivation (xiushen).

Systematic changes are necessary to turn the internship into a real site for moral formation, where virtue develops naturally amid good company, mentorship, and reflective practice. Interns ought to be immersed from the outset in clinical environments, where they are tasked with active patient care and communications, not relegated to passive ‘case-clerking’ or administrative routines. As they progress through rotations, interns should receive consistent, prompt, and constructive feedback—a ritualised habit of education. Being in the teacher’s role, supervisors should cultivate an open culture for exchanging ideas and trustworthiness, providing practical wisdom and consistent guidance, and guiding interns to reflect consciously on why and how their clinical decisions are grounded in the virtue of propriety from an ethical point of view. This facilitates harmony (he) without threatening the just hierarchy in medical settings, allowing interns to consult their seniors in confidence and to be taught by them as appropriate. These embody the Confucian ideal of studying through practice under virtuous tutors. Furthermore, standardised, competency-based benchmarks for baseline competence, regularly reviewed, would clarify reasonable expectations for supervisors and gauge the skills interns should have acquired at different stages of the internship. Clear guidelines for task delegation, tailored to the demands of different departments and specialties, would clarify interns’ responsibilities.

By refining the apprenticeship model to focus on reflective learning, reliable role models, and well-defined, role-appropriate expectations, the internship system can harmonise and fulfil what intern mishaps may depict as contradictory: ensuring patient well-being while nurturing caring, trustworthy, competent, and, above all, virtuous doctors. These measures would ensure that medical training is aligned with the Confucian concept of moral education as the basis for social harmony and cultivate physicians who are incarnations of humane excellence in service to others.

Authors: Trevor T. W. Wan¹ and Wai Tak Victor Li²

Affiliations: (1): Centre for Medical Ethics and Law, Li Ka Shing Faculty of Medicine and Faculty of Law, The University of Hong Kong, Hong Kong ; (2): Department of Medicine, Queen Mary Hospital, Hong Kong

Conflicts of interest: none declared