Whitcomb, Michael E. MD
During the past decade, members of the medical education community have devoted a great deal of time and effort trying to ensure that medical professionalism is being inculcated into medical students and residents. Indeed, an entire body of literature devoted to the topic has been created during that period, and many professional organizations, including the AAMC, have organized special conferences about professionalism or addressed that topic at their annual meetings. It is fair to say that the various aspects of medical professionalism, and how to teach and assess it, have been discussed repeatedly within the medical education community. So, where do things stand?
In my view, there’s a great deal of work yet to be done! In particular, in trying to foster professionalism, very little progress has been made in addressing a fundamental issue: the nature of the clinical environments in which students and residents learn medicine. For the most part, medical schools and residency programs have introduced various exercises into the curriculum that focus on professionalism, have developed assessment tools for identifying and quantifying what they would consider unprofessional behaviors, have established symbolic ways of orienting students and residents to their membership in the medical profession (white coat ceremonies and the taking of special oaths), and have implemented approaches for counseling students and residents about their behaviors.
Those actions are all well and good but certainly not adequate. That’s because we all know that if students and residents are not immersed in clinical learning environments that embody the highest ideals of medical professionalism, it is highly unlikely that most of them will be deeply grounded in those ideals when they emerge from their training. And it is also clear that it will be extremely difficult to change those learning environments. Nonetheless, there is a glimmer of hope.
Respected scholars are now beginning to speak out about the inadequacies of the approaches being used for inculcating professionalism into students and residents. By doing so, I think they will help spark efforts to transform the clinical environments in which students and residents are learning medicine. Given that, I think the Viewpoint pieces by Coulehan and Huddle in this month’s issue of the journal should be required reading for everyone holding leadership positions in medical schools and teaching hospitals, and for the faculty at those institutions as well.
These two essays are thoughtful, well written, and extremely thought-provoking. The authors bring different perspectives to the issue, but they agree that the current strategies for promoting medical professionalism are inadequate. And, importantly, they agree that it is personal experience that greatly helps students and residents realize what it means to be a truly professional physician and to develop the natural inclinations and habits to always act in the interests of their patients and the health of the public.
The two authors make powerful statements about what needs to be done if the medical education community really hopes to inculcate professionalism into those they teach. For example, Coulehan advocates the development of narrative-based professionalism in students and residents, as opposed to the rule-based professionalism now being “taught” by medical schools and residencies. For this to happen, the clinical learning environment must be transformed so that students and residents can see and experience the ideals of medical professionalism at work in shaping patients’ care and can better understand society’s expectations of them as future doctors. In my view, his recommendations for how medical schools and residencies can support the development of narrative-based professionalism in their students are right on target.
The Carnegie Foundation for the Advancement of Teaching is currently engaged in a project aimed at elucidating some of the issues of concern. The Preparation of the Professions Program is headed by the foundation’s president, Lee Shulman, and is being co-directed by Bill Sullivan and Ann Colby, senior scholars at the foundation. The project, which seeks to understand how current pedagogies support the development of professionalism in the fields of law, engineering, the clergy, nursing, and medicine, will be completed in the next few years. The foundation hopes that the project’s findings will lead to systematic and transformative changes in how the students studying those disciplines are being educated to meet their responsibilities to society.
In his recent book,1 Sullivan argues that the current approaches being used in educating doctors, as well as those studying other disciplines, are producing highly skilled technicians but not necessarily true professionals who understand their responsibilities to the society at large. He asserts that it is the loss of a shared sense of civic responsibility that threatens the future of the professions and that is responsible also, to a great extent, for the growing disenchantment that many members of the professions have about their careers.
He believes that medical education must change if the ideals of medical professionalism are to be inculcated into future practitioners. And to foster what Coulehan calls narrative-based professionalism, Sullivan believes that students and residents must experience three different kinds of apprenticeship:
* one that allows learners to acquire the knowledge base of medicine and the capacity to think like a competent physician;
* one that allow learners to acquire the skills necessary for the practice of one of the disciplines of medicine; and
* one that allows learners to acquire an understanding of the ethical standards, social roles, and responsibilities of the profession so that they grasp the meaning of the profession’s fundamental purposes.
In his view, it is the last form of apprenticeship that is most deficient in the current approaches used in educating doctors. And he suggests that this relates to the academic community’s preference for an analytic approach to education over one that is narrative and practical.
In this regard, Coulehan’s view that medical education programs must include socially relevant, service-oriented learning experiences is entirely consistent with Sullivan’s diagnosis of the problem. But it is important for medical educators to recognize that for those experiences to be meaningful, they must not be marginal to the educational process, since they play a critical role in providing the third kind of apprenticeship that Sullivan feels is so important if the profession of medicine is to experience a renewal of purpose.
We all have an important stake in seeing that this kind of learning occurs. It is time to stop focusing on the rule-based professionalism that dominates our current teaching. Instead, we must acknowledge the narrative basis of medicine and develop educational experiences that will allow students and residents to learn what it truly means to be a physician.
Michael E. Whitcomb, MD
1 Sullivan W. Work and Integrity. The Crisis and Promise of Professionalism in America. Jossey-Bass, 2004.