Future doctors' silence: An empirical study of declining speaking-up behavior among medical students

Speaking-up behavior is crucial for preventing patient harm, yet evidence suggests that increased clinical experience does not necessarily promote it. Gender, contextual factors, and prior patient safety training may also influence speaking-up tendencies, but research on their interaction remains limited. To address this gap, this study examines the impact of clinical experience, gender, patient safety training, and scenario severity on speaking-up behavior to inform targeted educational interventions.

This cross-sectional study analyzed 306 medical students from two cohorts (2020 and 2023) at a medical university in Northern Taiwan. A simulation-based assessment session evaluated students' speaking-up behavior in life-threatening and non-life-threatening medical error scenarios. Data on clinical experience, gender, and prior patient safety training were collected. Speaking-up behavior was assessed using the Speaking-Up Behavior Checklist, and binary logistic regression was conducted to examine associations.

Increased clinical experience was significantly associated with lower speaking-up behavior (Exp(B) = 0.916, p = 0.005), particularly among male students, while female students' behavior remained unchanged. Additionally, students were less likely to speak up in life-threatening scenarios (Exp(B) = 0.886, p = 0.007), while scenario type had no significant effect on those with less clinical experience. Prior patient safety training was not significantly associated with speaking-up behavior.

These findings suggest that clinical experience, gender, and scenario influence speaking-up behavior. While clinical skills improve with experience, heightened hierarchical awareness and professional relationships may increase hesitation. This implies the importance of structured policies, targeted training, and cultural transformation to foster a safe environment for speaking up. Future research should also examine psychological and organizational factors to better guide educational and systemic interventions.