Cohen, Jordan J. MD
When asked, most people express the desire to be treated by physicians who, in addition to being masters of their craft, care deeply about their patients. Each of these two characteristics—competency and caring—is a component of a broader set of attributes commonly denoted, respectively, as professionalism and humanism. Before addressing the question of how physicians’ professionalism might be linked to their humanism, it is necessary to understand what those words mean. Much has been written about each of these seemingly ephemeral concepts,1,2 and, rather than compare and contrast what various authors have written, let me cut to the chase with my own definitions.
Professionalism, in my view, is a way of acting. It comprises a set of observable behaviors.3,4 In aggregate, those behaviors, which in the context of medicine have been codified recently in the Physician Charter, are the means by which individual physicians fulfill the medical profession’s social contract with society.5,6 Based on a set of overarching principles (i.e., the primacy of patients’ interest, patients’ autonomy, and social justice), professionalism entails actions that are required of physicians to meet the expectations of patients and the public (see List 1).
It follows from this definition that individual physicians could, in theory, act in such a way as to fulfill all the expectations of professionalism without actually believing in the virtues or principles that underpin them—going through the motions, so to speak. From society’s perspective, insofar as the actions accomplished their purpose, such physicians would be doing their duty as professionals, however hypocritical or cynical their motivations.
Humanism, by contrast, is a way of being. It comprises a set of deep-seated personal convictions about one’s obligations to others, especially others in need. Humanism manifests itself by such personal attributes as altruism, duty, integrity, respect for others, and compassion. In the context of medical practice, humanistic physicians are intuitively and strongly motivated to adhere to the traditional virtues and expectations of their calling.
On the basis of these definitions, the link between humanism and professionalism can be summarized as follows: Humanism provides the passion that animates authentic professionalism.
There is an oft-quoted canard that says, “The most important thing for a politician to remember is to be sincere; if he can fake that, he’s got it made!” Just as politicians who attempt to fake sincerity are in constant danger of faltering and revealing their less savory character, so too are physicians whose professionalism lacks a solid foundation in humanism in constant danger of deviating from the ethical commitments of medicine.
In the absence of humanistic grounding, professionalism lacks authenticity; it is a thin veneer resting on a fragile and undependable frame. The challenges and frustrations of everyday medical practice pose innumerable opportunities and excuses for physicians to abandon their commitment to professionalism. Physicians who harbor the passion of humanism are best positioned to remain steadfast in fulfilling their professional responsibilities despite ever-present temptations to do otherwise.
Implications for Medical Education
Informing the admission process
The first and most obvious implication for medical education of the link between professionalism and humanism centers on the admission process. Successful applicants to medical school are, as a routine matter, expected to present solid evidence of their humanistic qualities. Indeed, a major challenge for admission committees is to identify candidates who, in addition to the requisite academic background and scholarly achievements, also possess the character traits indicative of success as humanistic physicians. Although efforts are being made to improve the tools available to assess applicants’ personal characteristics,7 those currently in use (e.g., personal interviews, letters of reference, documentation of extracurricular activities) do not seem to predict future performance in the humanism realm as reliably as grade-point averages (GPAs) and Medical College Admission Test (MCAT) scores predict scholastic performance.8 It is arguably for this reason that admission committees tend to base their decisions about whom to admit more on GPAs and MCAT scores than on other aspects of a candidate’s application.
A regrettable and presumably unintended consequence of this tilt toward GPAs and MCAT scores is that many prospective applicants justifiably perceive medical schools as being interested primarily in their academic credentials and as paying less, if any, attention to their personal qualities. As a result, many highly intelligent idealists, who would make excellent candidates for the profession, may fail even to apply because they think medical schools are only interested in what’s in their heads, not in what’s in their hearts.9 Indeed, what medical schools truly value in selecting future physicians is conveyed as much by the tacit and indirect messages they send to applicants as by the formal elements of their admission process. If medical schools wish to preserve the link between humanism and professionalism, they would be well advised to balance the strong message they send about the importance of grades and test scores with more visible evidence of their simultaneous interest in the humanistic attributes of their applicants.
Inculcating a commitment to professionalism
Considerable attention has been focused recently on the importance of strengthening the commitment of students and residents to medical professionalism. This issue of Academic Medicine is devoted to the topic of professionalism, and it consists largely of descriptions of successful efforts that medical schools throughout the country are making to position professionalism front and center among the learning objectives for their students. These articles and others in the medical education literature make clear that the formal, informal, and “hidden” curricula are being scrutinized for opportunities for improvement.10 Reliable techniques are being developed for evaluating students’ performance in the various domains of professionalism.11–13 Outcome studies have documented the value of in-school evidence of unprofessional behavior as a predictor of future disciplinary action by licensing boards.14 Remediation efforts are being devised for students who seem deficient in one or more aspects of professionalism.15 All of these efforts are to be commended, and more are to be encouraged. Indeed, no aspect of medical education should have a higher priority than ensuring that future physicians understand both the full weight of their responsibilities as professionals and the dangers to patients and the public from the current waning commitment by physicians to the tenets of professionalism.
As noted earlier, however, in the absence of deep-seated empathy and respect for the human condition, one’s commitment to professionalism would necessarily remain largely an intellectual exercise—what one might call skin-deep professionalism or cognate professionalism. Clearly, professionalism operating solely on an intellectual plane is better than no professionalism at all. But if medical educators desire to have the greatest impact here, they must not only convey the cognitive rationale and precepts of professionalism; they also must, as an integral component of the professionalism agenda, acknowledge and cultivate students’ and residents’ natural disposition toward humanism. Indeed, attempting to inculcate a commitment to professionalism without attending to the affect of humanism that animates it would be analogous to purchasing a Ferrari but neglecting to fill the gas tank. You might look good sitting in a fancy car, but it’s not likely to get you where you want to go.
Recognizing the role of humanism in professional development
Skeptics are likely to raise the objection here that the attributes of humanism are (or are not) developed early in life and that medical students are beyond the age when much, if any, improvement is possible. They might argue that it is sufficient to deny admission to those medical school applicants who seem to lack the desired humanistic attributes, in the belief that all who gain admission are equally—or at least adequately— endowed with those attributes. But it is common knowledge that matriculants to medical school, no matter how carefully selected, vary widely in temperament, personality, and readiness to be openly supportive of others. It seems axiomatic that whatever nascent humanism students are endowed with at the inception of medical school can only be reinforced and empowered by immersion in a culture that stresses the fundamental importance of altruism, duty, integrity, respect, and compassion as attributes of a good doctor. By the same token, of course, even the most humanistic matriculant will find it difficult to remain so if immersed in a culture that fails to esteem caring.
Sociologists tell us that cultural values are typically transmitted from one generation to the next by the way respected role models are observed to behave, by ceremonies that celebrate the values of the community, and by awards that publicly honor individual exemplars of those values.16–20 Each of these modes of transmission is clearly evident in the course of medical education. The effectiveness of role models is widely acknowledged as critically important in shaping students’ attitudes about their professional responsibilities, as well as in guiding career choices and in establishing specific patterns of practice. The ceremonial pageantry surrounding graduation from medical school helps to solemnize fundamental professional values, such as service to others and lifelong learning. Awards for exceptional scholarship, for research accomplishments, and for community service send powerful signals about what medicine values.
Humanistic care is acknowledged widely as a fundamental cultural value for medicine, yet, until recently, its relative importance has been conveyed to students and residents largely by the way they observed clinical faculty interacting with patients. Indeed, it was concern about the extent to which humanistic patient care seemed to be waning as a norm among clinical faculty (and others) that prompted the establishment of the Arnold P. Gold Foundation in 1988 and the introduction of its signature program, The White Coat Ceremony, which is typically conducted during orientation week for first-year students.21 The Gold Foundation has spawned several other activities to highlight the value of humanism in medicine; the most recent such activity—and potentially the most enduring one—has been the Gold Humanism Honor Society.22
The role of humanities in the medical school curriculum
Medical educators, both in the United States23 and elsewhere,24–26 have begun to recognize the value of integrating “medical humanities” into the curriculum. Defined as “a sustained interdisciplinary inquiry into aspects of medical practice, education and research expressly concerned with the human side of medicine,”27 medical humanities draws illustrative materials from history, philosophy, literature, music, the visual arts, and other modes of human expression in an effort to strengthen students’ understanding of the vital connection between the existential and clinical experiences of illness. Although outcomes data are sparse, it is hard to deny the putative benefits of integrating such “nonscientific” material into the curriculum as a means for nurturing medical students’ humanistic attributes. For example, engaging powerful narratives written by thoughtful patients (and doctors) can stimulate self-reflection and broaden a student’s understanding of the consequences of illness both for those directly affected and for their families.28,29 Moreover, serious engagement with medical humanities offers a unique and compelling way to tap into the emotional dimension of the clinical encounter and can validate for students what it means to be, and not just act like, a humanistic professional.
Professionalism is a way of behaving predicated on a conscious vow to place patients’ interests uppermost. Humanism is a way of being predicated on an innate predisposition to respond sympathetically to the needs of others. In the context of medicine, professionalism and humanism are best considered not as separate attributes of a good doctor but, rather, as intimately linked. Without a solid foundation of humanism to animate it, professionalism is overly dependent on good intentions, and it has little chance to prevail under the intense lure of self-interest rife in contemporary medical practice.
Nurturing the attributes of humanism in medical students and residents requires that medical educators use all of the modalities available for promoting a culture of caring in their institutions. Chief among those modalities are respected role models who unfailingly provide humanistic care, ceremonies that celebrate the attributes of humanism, awards that honor exemplars of the caring physician, and serious engagement with the medical humanities to provide vivid insights into what a humanistic professional is.
The author wishes to thank Fred Hafferty, PhD, for reviewing the manuscript and for his helpful comments.
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