When a Patient Becomes a Teaching Tool: Moral Injury in Medical Training

A second-year medical student walks into a locked psychiatric ward for the first time in his life. The doors close behind him with a sound he will not forget. Eighteen students and two attending physicians crowd into a dayroom, waiting to practice psychiatric interviewing on a real patient—a man admitted after a suicide attempt, described by the attending as stable enough to go home the next day and as a “good” learning opportunity. What happened in that room, and the unease it left behind, has become the subject of a reflective essay published in Academic Psychiatry by Maxwell Ackerman of Albert Einstein College of Medicine, a piece that is now resonating far beyond one teaching hospital because it names something many trainees feel but rarely have words for: moral injury.

The moment that anchored the essay is deceptively small. When the patient entered the dayroom and saw the crowd, his expression shifted from composed to startled, guarded, overwhelmed. “I was not aware that there were going to be so many people here. I thought it was going to be just one,” he said. No one in the room paused to acknowledge that sentence. The first student interviewer opened with a warm but impersonal “How are we feeling today?” and the exercise proceeded. Ackerman writes that his stomach tightened as he watched the patient redirect questions about painful parts of his history, reframe details drawn from his chart, and emphasize the positives of his imminent discharge. At the time, he wondered whether the patient was minimizing his illness. In retrospect, he wonders whether the man was simply protecting himself.

The technical framing that Ackerman brings to this memory comes from a growing literature on moral injury in medical education. Moral injury, in this context, is distinct from burnout and from secondary traumatic stress. It describes the distress that arises when a person participates in, witnesses, or fails to prevent events that conflict with their own deeply held moral values. Nemiroff and colleagues, writing in Advances in Health Sciences Education in 2024, documented how medical students can experience precisely this kind of distress when the informal lessons of clinical training—the hidden curriculum of what is actually done on the wards—run counter to the ethics students are formally taught or intuitively feel. Ackerman describes leaving the ward that day with exactly that dissonance: he had come to learn how to help people, and instead he found himself wondering whether he had participated in harm. “Was harm done? I still don’t know,” he writes, refusing the comfort of an easy answer.

Central to the essay’s argument is the question of informed consent, and here the reflection draws on more formal bioethical analysis. Citing work by Ng on informed consent in clinical practice, Ackerman points out that patients with psychiatric conditions face unique barriers to giving meaningful consent. These barriers are compounded by institutional pressure and by stark power asymmetry: a patient on an inpatient unit, particularly one approaching discharge, may feel compelled to agree to whatever is asked of him without fully grasping what he is agreeing to. The patient in the dayroom had not chosen his audience of eighteen. He did not control the questions, the pacing, or when the conversation would end. Ackerman describes the geometry of the scene sharply—the attending and the students on the outside, the patient in the center—and asks whether what looked like patient-centered care actually honored patient autonomy or dignity at all.

The essay also situates the episode within the framework of trauma-informed care, an approach that has gained substantial traction in health services research. A 2023 systematic review published in Implementation Science Communications examined the barriers and enablers of implementing trauma-informed care across healthcare settings and underscored a counterintuitive finding: healthcare environments can themselves be re-traumatizing, particularly when they limit a patient’s sense of autonomy and control. For psychiatric patients, who disproportionately carry histories of trauma, stigma, and encounters with systems that have failed them, this risk is amplified. Read through that lens, the patient’s avoidance and withdrawal during the interview may not have signaled resistance or clinical minimization at all, but self-protection—a coping strategy in a situation where every structural feature stripped him of control.

What makes the reflection scientifically interesting rather than merely confessional is that Ackerman does not argue against early clinical exposure. The evidence for its value is real and well documented. A qualitative study published in BMC Medical Education in 2022 found that early clinical experiences foster motivation, bridge the gap between classroom theory and bedside practice, and support the development of professional identity—outcomes Ackerman says he has felt himself. The problem he identifies is not exposure per se but the conditions under which it happens. Growth, he argues, should not come at the cost of someone else’s agency. The tension between a learner’s legitimate educational needs and a patient’s psychological safety is a genuine design problem in medical education, and it has a known set of solutions.

Chief among those solutions is the standardized patient. Standardized patients are trained actors who portray clinical scenarios consistently and consent fully to the educational use of their participation, and a 2025 meta-analysis in Frontiers of Medicine found that standardized-patient-based training is more effective than role-playing for building clinical skills, including psychiatric interviewing. SP programs exist precisely to give novices deliberate practice while protecting vulnerable patients from the risks of learner inexperience. Against that benchmark, the dayroom scene looks like a shortcut: real patients used for interview practice in a group setting, with consent processes that at least one participant experienced as inadequate. Ackerman is careful to note that what he witnessed does not reflect a lack of values at his institution. It reflects, in his words, a gap between what medicine teaches and how a single well-intentioned moment can unfold in practice—a gap that, he argues, shows up across psychiatric training nationwide.

The remedies he points to are not exotic. Many programs already work to close this gap with smaller learner groups, meaningful informed-consent processes, genuine options for patients to decline without consequence, and trauma-informed preparation before students ever step onto a ward. None of these are new ideas, Ackerman writes; they are commitments the field has already made, ones it is still learning to carry out consistently. The essay’s power lies in showing how easily those commitments can dissolve in the logistics of a busy teaching service, where eighteen students need interview experience, an attending needs to fill a session, and a patient who is “stable enough” becomes the path of least resistance. Good intentions, the essay insists, do not erase impact, and the ethical principle of nonmaleficence must extend beyond physical harm to psychological and emotional safety.

There is also a quieter, systemic lesson in the piece about the emotional education of future physicians. Ackerman and his peers left the ward feeling uneasy, complicit, and disturbed, but at the time he “did not have language for it.” Only later, through reflection and conversations outside his group, did he come to understand the experience as moral injury. That lag matters. If trainees cannot name the ethical discomfort they experience in real time, they cannot escalate it, document it, or convert it into institutional change—and the hidden curriculum keeps teaching the wrong lessons by default. Programs that build structured ethical debriefing into early clinical exposure would not only protect patients; they would give students the vocabulary to process moments like the dayroom scene before those moments calcify into cynicism or numbness, two of the documented downstream costs of unaddressed moral injury in medicine.

The man in the center of the room walked in expecting a single interviewer and found an audience. He walked out, by all accounts, to go home the next day. What remains unresolved—deliberately, in Ackerman’s telling—is whether the exchange helped more than it hurt, and whether that calculus was ever his to make. The essay closes on that ambiguity rather than resolving it, and that is arguably its most important contribution: an invitation to medical educators, ethicists, and students to sit with the discomfort long enough to redesign the systems that produce it. An earlier version of the work was presented at the Annual Medical Student Ethics Conference in 2025, suggesting the conversation it opens is already moving through the community best positioned to act on it. The patient’s single sentence—I thought it was going to be just one—may end up doing more for patient-centered psychiatric education than any lecture on the subject could.

Subject of Research: Moral injury and patient consent in psychiatric medical education

Article Title: The Man in the Center of the Room: A Reflection on Moral Injury in Medical Training

Article References: Ackerman, M. (2026). The Man in the Center of the Room: A Reflection on Moral Injury in Medical Training. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02453-2

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02453-2

Keywords: moral injury, medical education, psychiatry, informed consent, trauma-informed care, standardized patients, hidden curriculum, nonmaleficence, patient autonomy, clinical training, medical ethics, Academic Psychiatry