Medical professionalism is the keystone of the social contract between medicine and the public at large. Recognizing the growing significance of this, medical educators are increasingly shaping their curricula to emphasize the importance of professionalism. Yet academic medicine’s leaders, prompted to a great extent by Tom Inui’s masterful essay, “A Flag in the Wind,” now see the critical importance of going beyond curricular strategies and taking steps to ensure that the medical school environment and culture support students’ professional development. In this issue of the journal, there is a wealth of information about approaches that medical school deans, other institutional leaders, and faculties have adopted in recent years to achieve that goal.
Before commenting further, I want to acknowledge the time and effort that Linda Blank invested in making this theme issue a reality by serving as its guest editor. In February of this year, Linda completed her tenure as a Petersdorf Scholar in Residence in the association’s Division of Medical Education. During that time, she conducted a project to document what deans and faculties are doing to enhance the presence of medical professionalism in the cultures of their institutions. It was only natural that Linda would use the experience she gained in conducting the project to pull together most of the articles that appear this month. I also appreciate Linda’s contributions to this editorial.
In addition, I thank Anne Farmakidis, who became the journal’s assistant managing editor in June, for coordinating the development of the entire issue. Taken as a whole, the collection of articles tells a powerful story about one of the most important challenges facing the academic medicine community: how to create learning environments that will allow students (and residents) to become true professionals as they acquire the knowledge and skills required to provide high-quality patient care.
The need to respond vigorously to that challenge is presented forcefully in the lead Viewpoint piece by Brainard and Brislen. In many of the articles that follow, the authors note that it was the adverse effects of certain experiences on their students that prompted them to begin the transformation of their institutions’ cultures. But none of the authors describe the reality of those experiences as well as Brainard and Brislen. This should not be too surprising, since these two authors were medical students when they wrote their essay. And while the experiences they report—although collected over a four- year period in a variety of venues from 12 medical schools—were obtained informally, anyone intimately involved with student affairs issues will acknowledge that what those authors present accurately reflects many students’ experiences.
The range of initiatives being pursued at the institutions featured in the collection is really quite remarkable. Readers will note that most describe an initiative that is relatively recent and is focused to a great extent on a specific target. The fact is, the transformation of the culture of an institution requires an enduring commitment. This important point is reflected in the article by Smith and colleagues, who describe the process that has been under way at the University of Texas Medical Branch in Galveston for over a decade.
While it is clearly important to focus on transforming the learning environments of the academic institutions where students and residents are studying medicine, Swick makes another extremely important point in his article. Given the growing number of clinical learning experiences that students participate in beyond the walls of academic medical centers, it is important to pay attention to the professionalism manifested by practicing physicians, not only for what it means to the patients they care for, but also for the impact it has on students who observe them providing care. And in their article, Viggiano and colleagues describe the various approaches used to ensure that this important principle is followed in providing care to patients at the Mayo Clinic.
The article by Smith and colleagues makes another important point: The changes that are required to transform the institutional culture are almost certainly not going to occur in the absence of strong institutional leadership. It is no accident that the deans of the medical schools featured in the collection are the senior authors of the articles that appear. And in his Viewpoint piece, Craig Brater, dean of the Indiana University School of Medicine, provides a very personal perspective on his involvement in the process at Indiana University, and describes movingly what it has meant to him.
Finally, the collection gives readers an opportunity to reflect on other aspects of the medical school experience that might be changed to bring a greater focus to the importance of professionalism in medicine. For example, in arguing the importance of distinguishing between humanism and professionalism, Cohen makes a critically important point: humanism provides the passion that animates authentic professionalism. If this is true—and I believe it is—shouldn’t medical schools be paying much more attention to the humanistic qualities of the students they admit and how those qualities are enriched as they progress through the educational program?
Needless to say, I think the answer must be an emphatic yes if the initiatives under way in medical schools are to have their greatest impact on the professional and humanistic behaviors of their students as they progress into practice. And as I suggested last month,1 such behaviors must be at the core of the students’ understanding of what it means to be a physician.
Michael E. Whitcomb, MD