Quaintance, Jennifer L. PhD; Arnold, Louise PhD; Thompson, George S. MD
The topic of professionalism in medicine continues to garner the attention of the medical education community, and medical educators struggle with teaching professionalism. To teach it, medical educators need to be clear about what professionalism entails. There has been considerable discussion about the definition of professionalism, and many organizations and individuals have presented their understanding of medical professionalism.1–3 At the core, these various perspectives are quite similar. The definitions emphasize key principles and behaviors such as humanism, accountability, altruism, and excellence and may include clinical competence, ethical and legal understanding, and communication skills. These definitions can guide what we teach about medical professionalism, but we must also consider how we teach professionalism so that students can internalize what we teach them. Constructs such as explicit role modeling, situated learning, and appreciative inquiry can shed light on how to teach professionalism.
Medical educators have suggested that role modeling is the method most frequently used to teach about professionalism, but they agree that role modeling alone is not sufficient for inculcating professional attitudes and values in medical students.4–8 Rather, students need faculty members to be more purposeful and explicit in their teaching and modeling of professionalism.4 Effective physician role models enable learners to internalize the principles of professionalism so that learners themselves act professionally.6 These physician role models practice what they preach by regularly demonstrating professionalism and then preach what they practice by providing compelling, explicit justification for their actions.6 They productively and sensitively discuss their own strivings toward professionalism and their own shortcomings while teaching students.6 They are not silent models.
The widely used educational theory, situated learning, offers guidance on how to more effectively use role models and mentors to transmit professional attitudes and behaviors. Situated learning theory recognizes the importance of the learning that occurs as a result of the interactions among learners, their environment, and other participants, such as role models within the environment.8 Particularly important to the learning process is talk; learners come to a deeper understanding of their role in the environment through “talking about” and “listening to talk” about key elements of the physician's role.8 Advocates of situated learning contend that learning is most effective when there is a balance between explicit teaching (listening to talk) and active participation in (talking about) authentic, “real-world” activities. Situated learning emphasizes the role of authentic activities in helping learners apply abstract concepts in useful ways, which will lead to greater internalization of the concepts.4,6,8,9 The internalization of these concepts can be enhanced even further by encouraging learners to engage in active reflection and through their witnessing role models who are engaged in active reflection.9,10 Physician educators are in a unique position to teach students about the attitudes and behaviors of professionalism by encouraging students to listen to talk during formal didactic sessions, informal conversations, or role modeling during patient interactions and also by encouraging students to talk about their own experiences, triumphs, and struggles with professionalism.
Although role models can have an important and positive influence on students' development of professionalism, the influence of negative role models is pervasive and can be destructive.4,6,11–13 It is appropriate, then, that much of the literature on medical professionalism focuses on the lapses of faculty, residents, and students. This focus is valuable because it begins to elucidate students' and physicians' perspectives on lapses in professionalism and potential causes of the lapses.14–16
It is equally valuable to consider the professional behaviors and attitudes toward which faculty and students should strive and the methods by which those behaviors and attitudes are conveyed to students. In this respect, appreciative inquiry methodology can provide unique guidance. It proposes that lasting organizational change occurs as a result of focusing on where the organization is headed rather than focusing on where the organization has faltered.17 Appreciative inquiry also encourages the development of a “vocabulary of hope” to dramatically move the focus from the negative toward the positive.18 Medical educators at the Indiana University School of Medicine have made important strides toward successfully implementing appreciative inquiry strategies and have seen meaningful and considerable changes in the culture of professionalism at their institution.19,20
Thus, to internalize professionalism, students need (1) to receive explicit teaching about behaviors and values of professionalism within authentic contexts, (2) to witness as their role models reflect on their own understanding of and experiences with professionalism, (3) to reflect on their own experiences, and (4) to focus on and be exposed to positive instances of professionalism. The question then becomes: How can medical educators with limited time and resources accomplish all of these tasks in such a way that students will receive and internalize the intended messages about the formal values of professionalism?
Drawing from the literature on teaching professionalism, we implemented a project to enable students and faculty to talk about positive examples of professionalism in a comfortable environment. The purpose of this report is to describe the project, which consisted of conversations between students and faculty on the topic of professionalism and the students' reflections about those conversations. This report will answer three questions: (1) What are the components of the project? (2) How was it implemented? (3) What did the students take away from the conversations they had with faculty members?
Rationale and purpose of the project
Faculty requests for assistance in improving their teaching of professionalism prompted this project. After reviewing the literature on the teaching of professionalism, we decided to use situated learning theory and the appreciative inquiry method to guide the development of the project. Situated learning theory indicates that a balance between explicit teaching and participation in authentic, real-world activities is important. We also knew, from the negative perceptions of lectures on professionalism that students expressed in their course evaluations, that the influence of formal didactic sessions would be minimal. We needed to create an environment within which students and faculty could have conversations about professionalism that would allow for explicit teaching in an engaging and authentic context. Furthermore, we found inspiration from the efforts at the Indiana University School of Medicine and decided to apply the appreciative inquiry method at our institution. Thus, the purpose of the project was to increase medical students' awareness and appreciation of the principles of professionalism and to provide contexts within which faculty members and students could discuss professionalism.
Components of the project and its implementation
With approval from our institution's institutional review board, we implemented the project in 2004 at the University of Missouri–Kansas City School of Medicine, a public school with a six-year combined baccalaureate degree/MD program. Throughout the entire program, students are part of learning communities led by physicians, who in this role are called docents. In their first year, students are placed in 12-member learning communities, where they shadow one docent twice a week for two years (year 1–2 communities). In their third year, students join a learning community consisting of approximately 12 students drawn equally from years 3, 4, 5, and 6 of the program (year 3–6 communities). In year 3, students attend a weekly continuing care clinic with their year 3–6 communities. In years 4 to 6, students continue to attend the weekly clinic and also participate, for two months of each year, in internal medicine care of inpatients with their year 3–6 communities.
The docents, who are internists, formally serve as role models, advisors, and instructors for the student members of the learning community. Students consistently report in the Association of American Medical Colleges' Graduation Questionnaire and in program evaluation studies21 that their docents are very influential role models.
At the request of two of us (L.A. and G.S.T.), the chair of the Department of Medicine strongly encouraged docents to incorporate the project into the ongoing educational activities for their learning community. In addition, L.A. and G.S.T. recruited one to three student volunteers within each learning community to carry out the interviews. The individual learning communities scheduled the interviews so that as many members as possible could attend. No incentives for participation were offered to either docents or students. The project consisted of two components: students' interviews of their docents and students' reflections on and writing about the stories their docents told.
One of us (G.S.T.) trained 84 students and 36 docents to participate in the interviews. Training for students (90 minutes) and docents (15 minutes) allowed them to become familiar with the interview guide, which emphasized that the interview was designed to elicit positive examples of professionalism and that the participants should avoid sharing negative examples. Student training included substantial role-playing so that the students could become comfortable in their role as interviewer.
The interviews typically occurred in a small-group setting, either before or after a learning community's clinical teaching session, and they lasted between 30 minutes and an hour. One to three students asked questions of their docent, and the remaining 9 to 11 students observed the interview. Most of the interviews involved year 3–6 learning communities, although several of the year 1–2 learning communities also conducted interviews of their docents. A total of 62 students interviewed 33 docents, and 193 additional students observed the interviews.
The interviews were semistructured. The interview guide consisted of nine topic areas suggested by the following requests:
* Tell us about a time when you or another physician went the extra mile to help a patient.
* Tell us about a time when you or another physician acted with respect, empathy, or compassion for a patient.
* Tell us about a time [when you witnessed] a physician who followed the highest standards of behavior and refused to violate his/her personal and/or professional code.
* Tell us about a time [when you witnessed] a physician who fulfilled his/her responsibilities and obligations.
* [Tell us about] a time when you felt you were really learning something new, meaningful, and helpful to the health of your patients or your community.
* Describe a physician who seems to [carry] his/her responsibilities to patients easily and to freely commit to serving patients or others without feeling burdened.
* Tell us the story of what inspired you to start thinking about becoming a doctor.
* Tell us a story about a time when you felt most involved in, most excited about, or most satisfied with your practice of medicine.
* Tell us a story about some things you value deeply—specifically, things you value about (1) yourself, (2) the nature of your work, and (3) the medical profession.
We instructed students and docents to discuss at least three of these areas; most of the interviews addressed all nine requests.
We invited the student interviewers and observers to share the narratives they heard by posting them to a project Web site. The directions for posting were as follows:
Please recount the narratives shared during your interview for each of the questions discussed. If the question was not asked or discussed, leave the response box blank. At a minimum, recount the best story told for each question. You also have an opportunity to recount other shared stories if you wish. Again, if no other stories were shared or [if] you do not choose to recount additional stories, leave the response box blank. You only need to recount the story, as close to verbatim as possible; you do not need to report here any discussion that resulted from telling the story.
We also asked the students to reflect on a narrative that was particularly meaningful for them by responding to these two requests: (1) “Please tell us what this story taught you about being professional,” and (2) “Please describe how you imagine that [your approach to] your work... [or attitude toward professionalism] may change as a result of hearing and learning from this story.”
Thirty-six students wrote a total of 132 narratives (ranging in length from 37 to 1,095 words). Each student offered his or her reflections on one narrative of his or her choice. Reflections ranged in length from 10 to 386 words. We asked the docents to check the students' narratives for accuracy. None of the docents took issue with any of the narratives.
We analyzed the content of all of the narratives and reflections. Two of us (J.Q. and L.A.) developed the coding scheme for the narratives through an iterative process involving periods of independent coding and discussion to resolve disagreements. Open coding of a random sample of approximately 20 narratives indicated that the data closely matched existing definitions of professionalism. We selected the definition of professionalism proposed by Arnold and Stern1 to guide the data analysis because that definition is succinct and yet comprehensive in covering principles included in other definitions of professionalism. We used the definition to craft criteria for inclusion and exclusion and to arrive at a final coding scheme to use in the analysis of the 132 narratives. To provide validity evidence, we trained a third researcher, who was not previously involved in the project, to use the coding scheme. Then we independently coded a random sample of 26 narratives (20% of the total). We resolved the few disagreements between the initial and subsequent coding through discussion.
To identify the principles of professionalism identified in the reflections, we took the same analytic approach as we used for the narratives. Two of us (J.Q. and L.A.) also used standard open-coding techniques to discover the students' depth of awareness about professionalism principles, the ways that students derived meaning from the narratives, and the ways that the process supported the development of their knowledge of, attitudes about, and skills in professionalism. After reading a random sample of 20 reflections and independently generating initial impressions, we collaborated in creating an open-coding scheme. We refined the initial scheme through paragraph-by-paragraph comparison and negotiation and then verified the scheme by analyzing the remaining reflections. As we did for the analysis of the narratives, we added a third investigator (G.S.T.), who was not involved in developing the initial coding scheme for the reflections, to validate the coding scheme by independently coding a random sample of 20% of the reflections. There were no disagreements between the coders.
According to the students' narratives, docents told stories about the principles of professionalism—humanism, accountability, altruism, and excellence. The number of subthemes found in the narratives matched the richness and complexity that characterize many definitions of professionalism.1–3
Docents' stories embedded humanism in relationships: “Dr. X provided years of routine care that culminated in his being present for the patient and his wife when the patient died.” Many stories were about caring, compassion, kindness, and empathy, all subthemes of humanism. A neurosurgeon, for example, was particularly attentive to the emotional needs of a family who had lost their father: “His kindness disproved the stereotype of surgeons' behavior.” Other stories were about respect for others and frequently highlighted caring for the whole patient as an example of respect. Honesty, integrity, and humility were also described as being vital to humanism: “You always know exactly where you stand with her; there are no hidden agendas or secondary motives.”
Docents' stories described accountability as the passing of knowledge and skill to the next generation, as well as service to the community and general public. Another frequently mentioned theme was advocacy for patients:
After the patient [a sex offender] had been hospitalized for several weeks, I was pressured to discharge him... to a halfway house. I continued to look for another option.... I kept him in the hospital until I found an [appropriate] facility that agreed to take him.
A different docent's story also told about free acceptance of duty:
On a flight, over the intercom came a plea for physicians to assist a passenger in pain. I didn't feel an obligation to work, since I wasn't on call or in the hospital. But guilt crept over [me], and I got up. At the end of the flight, the flight attendant gave me a sock puppet. I keep it on my table as a reminder of my duty as a healer.
Docents' stories depicted altruism primarily as self-sacrifice— expending extraordinary time or effort in patient care; seeing patients at home, in shelters, or in nursing homes; and caring for patients in the face of risks to oneself. For example, “There was no one else to donate blood to this little African boy. My docent and the boy had the same blood type, so she donated her own blood to him.” Putting patients first and caring for patients in crisis situations were other subthemes of altruism. The stories also recognized the critical importance of altruism in patient care: “A doctor's poise and altruistic manner determine whether or not he will receive poor information, [which could lead] to a poor diagnosis, poor treatment, and possibly lawsuits.”
Docents' stories framed excellence as involving lifelong learning, as being an important way to avoid stagnation, and as recognizing and admitting mistakes: “A person is only as good a doctor as [his or her] most recent mistake.” The narratives expressed admiration of physicians who conducted research, published, and moved medical knowledge forward and of those whose curiosity, thoroughness, effort, and persistence led to quality patient care. One docent said, “My associate believed the patient's arm could be saved from amputation if a special orthotic could be designed... and he [saw to it that this was done].” Often, the narratives recognized outstanding expertise and a striving to do more than the minimum, so as to meet exceptional standards, as aspects of excellence. Some of the narratives included reports of extraordinary behavior that demonstrated caring and compassion, rather than technical brilliance or persistence, as a part of excellence:
Dr. Y went the extra mile for all his patients. He knew [that] patients can get shuffled around between different clinics. [So] he cared for his patients in all of the ways that he could; for example, he would clip the toenails of patients who had mobility restrictions and couldn't do it themselves, even though he could have simply sent them to a podiatrist.
Conflicts between principles.
Sometimes the narratives explored conflicts between different principles of professionalism. In the quotation, a docent provides an example of a conflict between humanism and accountability to an institutional policy on pets:
A homeless man arrived with his dog. Dr. T decided [that the man] needed to be admitted, but he refused because he didn't want to leave his dog alone.... Dr. T offered to take care of the dog, who spent the rest of the shift in the employees' lounge, and a nurse took the dog home with her.
Some narratives also described conflicts between the principles of professionalism and personal life:
When the docent's wife was pregnant with their second child, [the docent] tried his best to be considerate of the other faculty. He [arranged to take] time off around his wife's due date so he could be at home with her and [could] care for their new baby. He was conscious of the fact that, if he did not come to work... or [if he] left suddenly in the midst of the day, he would leave another docent... with a double load.... However, the baby decided to come a week early.... He dutifully reported to work the morning after his wife's delivery.... As he was sitting in the outpatient clinic... another docent insisted that he leave and would not take “no” for an answer.
Narratives about this type of conflict either described the resolution of the conflict or left the conflict unresolved.
In their reflections, students demonstrated awareness of the same major principles of professionalism that the docents conveyed in their stories. For example, one docent talked about the early days of treating patients who were HIV-positive and related how much he appreciated the physicians who accepted their duty and put their fears of infection aside. The student wrote the following reflection identifying the concept of free acceptance of duty:
The story regarding setting high standards was particularly touching, in that it made me realize my purpose as a health care professional. There are times when I forget that being a physician is a label of privilege. As such, it is my duty to set aside my fears and help those who seek my skills as a physician. This story helped rekindle those aspects of this profession and helped me realize my duties.
The depth of awareness of the principles of professionalism that students demonstrated ranged from superficial to deep. A particularly deep reflection read, in part,
As future physicians, we must remember that we are individuals, born out of the same flesh and blood as our patients and endowed with the same vices and virtues as those we treat. We do not belong to some elitist, esoteric club, but, rather, we all belong to the same fraternity—that of humankind. Having spent the majority of my life exposed to the field of medicine, this is something that I have realized is often easy to forget. We must remember that at the very core of professionalism lie respect, humility, and honesty. Yes, ambition is good, but only when it is tempered by compassion. This is what distinguishes medicine from the free-market world in which we live.
An example of a surface-level reflection read,
[The docent's narrative] taught us the importance of acting professionally and [about] how all of your actions affect the patients and how they feel about themselves. Our attitudes and approaches to work will change because we will think about putting our patients' needs first and always treating them with respect and dignity.
A few students, mostly in the first year, missed the point of the faculty members' stories. For example, after hearing a faculty member talk about how his interest in psychology led him to choose psychiatry as a career because he felt he'd be able to do more good as a psychiatrist than as a psychologist, the student did not frame the reflection in terms of professionalism but saw the story as justification of pursuing one's self-interest:
This story has taught me that being a professional doesn't mean giving up on things that you like. Instead, it means taking your interests and developing them even further. Oftentimes I have gotten so caught up in what I am interested in that I don't see many of the possibilities that can result from my interest.... I think, after hearing this story, that I will be more willing to pursue my personal interests in the medical field rather than separating the two.
Students gave personal meaning to the narratives by applying the principles of professionalism to new contexts, empathizing with characters in the narratives, and exploring connections among professionalism principles. For example, one student likened the poor patient care characteristic of the beginning of the AIDS epidemic to the poor patient care often offered today to patients without health insurance. In response to a story about a group of residents who purchased baby clothes for a new, low-income teenage mother, another student noted, “[This story] taught that professionalism includes truly seeing the patients as people and learning about the lives they come from, and, by [doing] this, you can effectively treat their symptoms.”
The narratives served to develop students' knowledge, attitudes, and skills about professionalism in numerous ways.
1. They sparked new ideas about professionalism:I have always attempted to separate my emotions from the practice of medicine, especially when I feel [that] people [will] look at me as if I am overemotional. I feel now [that] I will find the happy balance between the two, as families and patients are okay with emotions.
2. They reinforced previously held conceptions of professionalism:The constant verbal badgering about how you need to remain professional in all of your doctor–patient relationships truly sinks in when you get it from someone you look up to and respect.
3. They suggested ways to resolve future professionalism conflicts:I would imagine that I will carefully watch the way I treat patients and friends. Sometimes, you treat others in a cold manner without even knowing it. So this story teaches me that I need to try my hardest to make the patient feel as though we are there to help them.
4. They heightened students' commitment to professionalism:Our work will change as a result of hearing these stories. We have more respect for our docent doctor, and also we try to learn from his behavior and achieve the highest satisfaction from our patients and peers. That means we have to give everything we have, listen to our own hearts, and have our actions mirror the best interest of [our] patients, others, [our] community, and ourselves alike.
5. They offered inspiration:What he said was very inspirational, and I would like to think of him as a role model and a mentor, one [whom] I would like to model myself after.
6. They provided enjoyment:I really enjoyed the story of how the residents were able to pull together and help pay for a patient's medication.
7. Finally, the reflections revealed that the process of listening to and reflecting on the docents' stories deepened students' relationships with docents:This story was important to me because it makes me see the doctors that I am surrounded by every day... more [as] people.... It was reassuring to me to hear that my doctors, who seem to know everything, felt just as inadequate as I do now.
Analysis of the data revealed that the physicians' stories contained the same principles included in most definitions of medical professionalism.1–3 The narratives were stories about physicians who acted with honesty, respect, and compassion—that is, humanism; physicians who freely accepted their duty to help others and who advocated for patients who could not advocate for themselves—that is, accountability; physicians who sacrificed their time and sometimes even their personal safety in the interest of serving patients—that is, altruism; and physicians who strove to exceed expectations and who persisted until patients received the best possible care available—that is, excellence.
By far, of all of the principles of professionalism, the one the narratives most often talked about was humanism, which was typically described in terms of “going the extra mile” or exceeding expectations with regard to caring, compassion, and respect. Accountability was the next-most-often-addressed principle of professionalism; however, it lags far behind humanism in terms of the frequency of mention and the number of its subthemes. The narratives held physicians accountable to their patients, their colleagues, their students, and society at large. Altruism was the third-most-frequently cited principle in the narratives, where it was depicted as self-sacrifice and as putting patients' interests above physicians' interests. Finally, excellence was the principle cited least often in the narratives, and its mention typically involved a reference to lifelong learning.
Students' reflections on the narratives indicated that they learned from and valued the docents' stories. Students were able to identify and, more importantly, seemed to internalize many of the concepts embedded in the docents' stories. For example, they empathized with the patients, families, doctors, and other health care workers in the stories and routinely applied the concepts in the narratives to different contexts or to their own experiences. Some students were also able to articulate the relationships between key principles of professionalism. The narratives helped students to develop knowledge, attitudes, and skills related to professionalism by sparking new ideas, reinforcing older notions, and heightening a commitment to act professionally. A few students indicated that they felt they had been changed by the experience and said they would try to reflect their new attitude toward professionalism in their daily work with patients.
The conversations between physician role models and their students provided an opportunity for faculty members to be explicit4–8 about their professional values and to do so in an engaging manner. Furthermore, the students' reflections indicated that they understood the messages the faculty members were trying to impart. The stories that the docents told were almost exclusively set within their own authentic, clinically oriented experiences as physicians in training or physicians in practice in the community and on the medical school faculty. The conversations provided students with the opportunity to “listen to talk” about important concepts of professionalism.8 In addition, during many of the interviews, students and faculty had brief discussions, which allowed students an opportunity for “talking about” the issues embedded in the stories.8 Finally, the active reflection that students both witnessed from their docents and engaged in themselves was an important component of the project.9,10
The conversations have begun to build, in Ludema's phrase, a “vocabulary of hope.”18 The physicians had a great number of stories about professionalism to share with their students, and, with few exceptions, the stories were positive. Stories about simple acts, such as buying a patient a milkshake, or extraordinary acts, such as putting one's life in danger to rescue people from a collapsed building, can provide students with a sense of hope that acting professionally is one of the most rewarding aspects of medical practice. In turn, the students were often moved by these positive examples of professionalism, a response that led to feelings of inspiration and a renewed commitment to professionalism. Finally, this process helped to deepen students' relationships with faculty members and perhaps reinforced their importance as role models.
On the basis of our analysis of the narratives and reflections, we believe that the students learned a great deal about professionalism. Narrative storytelling, as a variant of appreciative inquiry and situated learning, seems to be an effective way for students to deepen their understanding and appreciation of professionalism.
We thank Angela Badger for her work as the “third researcher” in analyzing the data, Shannon McClain for managing the data, and the students and docents for participating in the project.
This project was funded by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and by a Sarah Morrison Grant from the University of Missouri–Kansas City School of Medicine.
The study was approved by the institutional review board of the University of Missouri–Kansas City School of Medicine.