WHITCOMB, MICHAEL E. MD
In recent years, medical school deans and faculties have recognized the importance of including formal instruction in medical professionalism in the curriculum. Indeed, the great majority of medical schools have added professionalism content to students' coursework in their first two years, and a number have introduced into clerkship experiences approaches for assessing professional behaviors. These developments are very important, but they are only the beginning of what is needed to produce physicians who recognize clearly the nature and scope of their responsibilities to the patients they care for and to the communities in which they work.
This issue of Academic Medicine contains a set of seven papers that address various issues related to the professional development of medical students. Two provide insight into methods that faculties might adopt to monitor how well medical students manifest professional behaviors. In her paper, Louise Arnold offers a comprehensive review of the various methods available for assessing both the individual elements of medical professionalism and the more global manifestations of professionalism that are reflected in the ways students interact with patients, patients' families, and other members of the health care team. Misch builds on the latter point. He argues that professionalism must be assessed by viewing the behaviors of learners in their entirety rather than by deconstructing their behaviors into the individual elements of professionalism. In other words, he maintains that it is the way that learners conduct themselves in their interactions with patients and others on a day-to-day basis that should be judged. He suggests a novel approach for the assessment of professionalism: members of the faculty who have been trained to recognize the elements of professionalism should be responsible for assessing how those elements are reflected in the totality of the students' behaviors. A third paper by Robins and colleagues examines the feasibility of adapting the taxonomy of the American Board of Internal Medicine's Project Professionalism to categorize the ethical issues medical students encounter.
The attention given to the assessment of students' professionalism by those two papers is clearly important. However, before focusing on methods for such assessment, deans and faculties must pay attention to the ways they promote professionalism among their students. In this regard, it is clear that the development of professionalism depends first and foremost on what students observe and experience as they go about their daily activities in the hospital, in the clinics, and in practicing physicians' offices. The kinds of experiences that they have in the clinical environment, particularly their interactions with faculty, will determine to a great degree how their professional attitudes and behaviors are shaped. Accordingly, the major challenge facing the medical education community—and, to be clear, the medical profession—is to make certain that the attitudes and behaviors that characterize medical professionalism are manifested on a regular and consistent basis in the clinical environments in which medicine is practiced and learned.
Therefore, to promote the professional development of students, it is essential that the clinical faculty understand how their attitudes and behaviors affect the students they come in contact with. In this regard, Delese Wear, in her essay on Shem's book, The House of God, reminds all of us that the clinical environment in which medical students learn clinical medicine has historically affected adversely the development of their professional attitudes and behaviors. But more to the point, her essay calls attention to the fact that many of the issues that concerned medical educators at the time Shem wrote his novel over 25 years ago continue to be of concern today. Ginsburg and colleagues reinforce this point by recording the kinds of lapses in professional behaviors that medical students regularly confront as they interact with members of the faculty, and by providing a framework for characterizing the nature of those lapses. Finally, Wilkes and Raven present a scholarly discussion of how the interactions that students have with faculty influence their views and attitudes about medicine. In so doing, they make an important observation—we need to understand far better than we now do the kinds of faculty behaviors that will have a positive influence on students.
Given that the House of God was published 25 years ago, one wonders why the lapses in professional behaviors noted by students continue to be such problems. I do not believe that those behaviors are purposeful. I doubt that faculty members intentionally act or speak to undermine the professional development of their students. It is important to recall, as the House of God makes clear, that many current faculty members were trained during a time when intimidation and abusive behavior were viewed as ways to harden future doctors so that they would not flinch when faced with difficult medical challenges. Those lessons—passed along from generation to generation of new doctors—are not easily unlearned.
Thus, to alter faculty attitudes that affect students adversely, it is important for the leadership of medical schools and teaching hospitals to make clear, through constructive educational means, that certain behaviors are not acceptable. Equally important, they should set forth a list of the explicit attitudes and behaviors that are likely to have a positive impact on the professional development of students and residents, and challenge the faculty to model those attitudes and behaviors as they go about their daily duties. In his paper (based on his President's Address at last year's AAMC annual meeting), Cohen proposes that the medical education community enter into a compact with students that would spell out the norms of behavior expected of all involved in the learning process.
The goal is clear—to create within medical schools and teaching hospitals an institutional culture that places value on commendable professional behaviors, and that is intolerant of behaviors that do not conform to established standards. The leadership of academic medicine's institutions should be held responsible for seeing that this occurs, and members of the faculty should then be held responsible for their own behaviors. To make this effort have meaning, methods for evaluating how well individual members of the faculty meet the established standards of professional behavior should be included as part of annual performance reviews conducted by deans and department chairs. If the goal stated above can be achieved, the profession of medicine will be well served. More important, it is the patients served by future generations of physicians who will benefit in the long run.