Jones, Trahern W.
Anatomy educators have long understood the role that professionalism education plays in the dissection laboratory.1 The process of dissecting human material forces students to address such issues as human mortality, their responsibility to the vulnerability of the deceased, their privileged position in society, and their commitment to scientific ideals, among other issues. Education leaders have offered a wealth of opinions and curricula dedicated specifically to teaching professionalism in first-year anatomy courses, such as those described in the July 2006 professionalism-centered issue of the journal Clinical Anatomy.2 Many view a medical student’s first human dissection as a sentinel moment in his or her career—without proper guidance, students may respond with solutions to these issues that are antithetical to medical professionalism.3,4
Students may perceive the above-mentioned professionalism challenges in anatomy as problems without easy solutions.5 The literature on medical professionalism suggests that students must develop an approach to addressing these ill-structured or ambiguous challenges.5 The very presentation of such challenges, then, offers a training ground for burgeoning health professionals, as they weigh the consequences of any proposed solutions. Many anatomy educators now seek to explicate such challenges with students to cultivate what could be called an “environment of awareness.” When students confront professionalism problems overtly, professionalism becomes an “as-lived” experience for them, relevant to learning anatomy and to the practice of medicine in general.6
That anatomy educators have risen to the challenge of teaching professionalism is laudable. However, professionalism education is a longitudinal process of acculturation; thus, one wonders, what happens to students after they leave the anatomy classroom? In their training, medical students spend 4 to 12 years navigating a shifting environment of hidden, null, or explicit curricula that have a significant impact on their attitudes and character.7–10 If professionalism issues—such as encountering mortality, enacting contracts with society and those who are most vulnerable, and upholding scientific excellence—are worthy of being taught in anatomy courses, then the same must be true in other basic science courses in an integrated, longitudinal professionalism curriculum.
Some argue that the professionalism challenges that students face in other basic science courses are not as intense as those that they face in anatomy courses, such as the dissection of human tissue, which may be difficult for students to process emotionally. Whereas the examples in anatomy are overt and perhaps predictable, students are exposed to similarly powerful situations in other basic science courses as well. Moreover, student learning suffers when professionalism is not addressed in the later basic science courses, as professionalism education effectively becomes a “null curriculum,”11 one that teaches students to compartmentalize professionalism questions so that they can be addressed in the anatomy classroom or during dedicated professionalism course work. What lesson is learned, for example, when students are taught that gallows humor is inappropriate during dissection, yet the same behavior is allowed when viewing samples during a pathology course? What lesson is learned when a preserved human brain does not generate discussion the same way that a whole, preserved human body does? What lesson is learned when there is no discussion of physicians’ societal responsibilities during a lecture on sexually transmitted infections?
As a medical student, I discussed professionalism challenges in my first-year anatomy course, during which my teachers encouraged and promoted discourse on medical professionalism. Looking back as a fourth-year student—having seen firsthand the necessity of practicing professionalism in clinical contexts—I have noted analogous opportunities for professionalism education in my other basic science courses. Although these courses presented challenges similar to those found in my anatomy course, the curricula rarely addressed them. My medical professionalism education was effectively put on hold during those middle two years—The environment of awareness that I had cultivated during anatomy was lost. In this Perspective, I summarize the relevant literature as I highlight specific professionalism challenges in anatomy and discuss how they are addressed by anatomy educators. Then I provide analogous examples of opportunities to teach professionalism in other basic science courses. I have used Slotnick and Hilton’s5 definition of “what professionals do” (i.e., exercising “sophisticated reflective judgment” and “principled ethical reasoning”) as a guiding, operational definition of professionalism.
The most immediate professionalism challenge in anatomy is a medical student’s confrontation with mortality in the dissection laboratory. This early contact with death is a provocative life event12–14 that has long been known to trigger a number of defense mechanisms in first-year medical students, some of which are antithetical to medical professionalism.15
Students’ reactions to dissection may include using gallows humor as a vehicle both to navigate the existential stresses of the anatomy laboratory and to engage in emotional socialization with classmates,16 which may allow students to gain a greater sense of emotional control by the end of the course.17 Anatomy educators have recognized that to build an environment of awareness to address this issue, students’ feelings may be redirected to literary and artistic reflections on death through a humanities co-curriculum, leading to more appropriate management of their reflections on mortality.18–20 In addition, feelings of mortality engendered in the process of dissection can prompt students to reflect on the relationship of their lives to their chosen profession, which many historical anatomists recognized. Andreas Vesalius, for example, included in one of his artfully designed illustrations “Vivitur ingenio, caetera mortis erunt” or “Genius lives on, all else is mortal.”21 Thus, not only must students learn to cope with the emotional stress caused by dissection but they must also reflect on their limited life spans as the boundaries within which they work. The literature provides evidence that reflection is a component to professional behavior that students should begin practicing early in their careers.22,23 Dissection has also been recognized as an opportunity for medical students to add a humanistic approach to their studies, and many have attempted to call attention to this challenge.3,24,25 Such an approach allows students to relate to the mortal aspects of the human condition rather than distance themselves through the unprofessional traits of cynicism and overzealous scientific detachment.
Students also encounter issues relating to mortality in other basic science courses. Autopsy experiences during a pathology course, for example, offer students subtle exposure to situations, such as the use of preserved human tissue sections in lecture, that may make their own emotional demands on students. Students should ask themselves whether or not working with parts of the human body, such as whole organs or sections, demands similar professional and emotional responses to confronting a cadaver. Does a brain preserved in formaldehyde deserve the same degree of existential consideration as a body preserved similarly? Furthermore, tissues often tell stories of death and disease that require some emotional processing—a section of human heart that demonstrates alcoholic myopathy recounts a story of human frailty. Medical students may interpret the story this tissue tells through the lens of biological signs and processes26 or, more fruitful to them as humanistic medical professionals, through the lens of suffering and frailty. Medical microbiology also offers subtle examples—In studying infectious diseases, students are presented with a litany of deadly epidemics throughout history. In such strictly biomedical course work, humans become things or numbers.26 In addition, medical students may view images of rabies victims tied to their gurneys. Their professors may tell them that, at this stage of the disease, the human being they are seeing is guaranteed to die. Silence on the human dimensions of this suffering invites the formation of a cold, clinical attitude in students. Such recurring themes on the fragility of human life deserve reflection. Feelings of mortality are not just a subject for the dissection laboratory; they must be brought forward during other basic science courses as well to cultivate an environment of awareness in medical students around professionalism challenges.
Enacting a Contract With the Vulnerable
Beyond inviting students to consider mortality, anatomy dissections place other emotional and professional challenges before students. The literature suggests that medical students undertaking human dissection peripherally mimic, with their cadaver donors, physicians’ contracts with those rendered vulnerable by illness.5,27 Indeed, treating a student’s cadaver as his or her first patient is a common theme in the literature.28–31 During dissection, students begin to practice the responsibilities of confidentiality and respect customarily practiced by physicians.32
Respect for the donor’s body is an issue with which students contend, and its practice is a skill relevant to medical professionalism.22,23 Students may be most visibly troubled by the roughness of dissection, and they may question whether they are upholding the respect that the vulnerable deserve by partaking in this act. Osteoporotic donors’ bodies are occasionally damaged by this rough handling, and anecdotal evidence indicates that students feel profound dismay at the trauma that these cadavers suffer during dissection.24,33 Students seem aware that they form a special contract with the vulnerable through dissection, and holding discussions is an excellent option for elucidating students’ views on what role respect plays in medical professionalism.24 Additionally, some anatomy educators have reported that breaches of confidentiality in the dissection laboratory present learning opportunities in professionalism and that they bring up these instances in discussion for students to reflect on professional behavior and confidentiality.34 Likewise, respect for the deceased is a regular topic of discussion in dissection laboratories, and a number of programs explore with students what behavior is appropriate when handling human remains.24,35 Some educators encourage students to reflect on respect by subtly shifting from using the terms “cadaver” and “corpse” to “donor,” thereby implying personhood rather than dehumanized objectification.35
Analogous challenges are found in other basic science courses as well. Students could address issues related to respect and confidentiality during a pathology course, where the handling of autopsy specimens figures prominently. Many of the same issues that students face when dealing with body donors also arise when dealing with donors of any human tissue and provide opportunities for professionalism education. Of particular interest are such cases as that of Henrietta Lacks, from whom researchers derived the “immortal” HeLa cell line and whose story begs a more nuanced discussion of consent, race, and education in the practice of medical science.36 A medical microbiology course also presents interesting professionalism challenges with regard to respect and patient confidentiality, such as students’ consideration of sexually transmitted infections. In addition, neurology educators share a responsibility to expose students to questions about comatose patients and brain death, such as the physicians’ duties to humanely care for and respect these most vulnerable patients, as well as the ethics of withdrawing life support.
Enacting a Contract With Society
Scholars interpret professionalism, including physicians’ privilege and responsibility to society, as a mechanism by which physicians enter into a social contract with the public.37 Western societies accept and expect that medical professionals in their nations engage in the dissection of human material for the sake of improving the body of medical knowledge. In the past, the dissection of human material bore a profound stigma in many of these societies.38 The burden of “donation” was assigned to criminals and indigent hospital inmates for centuries; through this practice, medical professionals held a kind of power over the oppressed and marginalized.38,39 Through an arduous process of cultural change, voluntary body donation programs in North America and Europe came to replace such Dickensian measures,40 but this history illustrates a time when the medical profession breached its social contract and betrayed a vulnerable sector of society. Students who consider the history behind the anatomical sciences may contemplate whether such events are examples of failed medical professionalism. They also may ask themselves why they are accorded the privilege of dissecting human material.
In their discussions of professionalism, anatomy educators have focused somewhat less on these questions, though some medical humanities curricula have sought to draw students’ attention to anatomy’s historical role in enacting physicians’ social contract.41 Educators seem to find the question complex and debatable whether dissection’s pedagogical benefits outweigh its societal costs.42–45 Answering this question also invites medical students to discuss society’s expectations of them in exchange for the privilege of dissecting human tissue.
There are similarities to these issues in other disciplines as well. In a pathology course, for example, medical students have the privilege of dissecting human bodies and perusing specimens resected from dead or dying patients, which can easily raise the same questions regarding social contracts. Other disciplines may similarly address physicians’ privileges and responsibilities to society—Learning pharmacology could provoke discussions of clinical trials, how they are funded and performed, and who reaps the rewards of successful research programs. Similar questions arise in medical microbiology courses when conducting vaccine research. In psychiatry, professors and students could discuss numerous issues pertinent to professionalism, such as physicians’ duties to balance patient and societal safety, to determine physicians’ capacity for decision making, and to debate institutionalizing patients without consent.
Autopsy: To See for Oneself
The process of human dissection is one of discovery and insight. The word autopsy comes from the Greek word meaning “to see for oneself”—precisely the means by which students are trained as burgeoning medical professionals in the dissection laboratory. Galen described this venture: “if anyone wishes to observe the works of Nature, he should put his trust not in books on anatomy but in his own eyes.”46 As medical students engage in a tactile exploration of the human body, they implicitly explore the foundations of medical knowledge and the medical profession’s obligations to scientific excellence.
Conducting an autopsy offers physicians the opportunity to think critically and extend the fields of medicine and biology. Training students to espouse these qualities and habits-of-mind is essential to producing high-quality medical professionals.47 In effect, medical students, through their own efforts in the dissection laboratory, repeat the same historical arc of awe, curiosity, and rationalization of the body as did their forebears. They also learn to question their own assumptions and confirm what they learned from their textbooks through direct experience. The value of direct experience in discovery is best described by Jacobus Sylvius in his 1555 Manual of Anatomy:
It is much better that you should learn the manner of cutting by eye and touch than by reading and listening. For reading alone never taught anyone how to sail a ship, to lead an army, nor to compound a medicine, which is done rather by the use of one’s own sight and the training of one’s own hands.48
Other basic science courses may foster such professionalism training by engaging students in the acts of seeing, doing, reflecting, and using a personal lens. Autopsies in pathology offer students the opportunity to discover a patient’s cause of death through direct observation. Nephrology courses may require students to undertake a 24-hour urine collection to examine their own kidney function. Pulmonology courses may encourage students to undergo spirometry to observe and correlate such values as tidal volume, minute ventilation, vital capacity, etc. Medical microbiology courses may require students to culture bacteria on agar plates and stain slides. Such basic science courses take the additional step beyond merely teaching scientific knowledge—They teach students the principle of autopsy, seeing for oneself. In doing so, they offer students opportunities to further their medical professionalism education. In this sense, educators should grant laboratory sections a certain degree of protection during ongoing curriculum revisions, given that they are an important venue for students to engage in seeing, doing, and reflecting with a personal lens on aspects of medical science. Alarmingly, recent evidence indicates that, even in anatomy, such practical course work is being cut.49,50
The Potential for Longitudinal Professionalism Education
The anatomical sciences are ideally situated to promote professionalism education; perhaps this is the reason why anatomy educators are advancing this effort in the basic sciences. Historically, all medical practitioners have encountered professionalism challenges in the course of their work, yet the practice of these sciences rarely required student participation in their daily struggles. Medical schools in the past often placed barriers between the lecture hall and real-life situations, except in the case of anatomy. Performing a dissection, the traditional method of learning anatomy, required students to learn the skill sets practiced daily by anatomists, thus providing no theoretical division between lecture and practice. Recently, this barrier between education in other basic sciences and clinical practice has been somewhat deconstructed through the use of simulation and standardized patients to give students a head start on the clinical years, perhaps making the need for medical professionalism education in the preclinical years more relevant than ever before.
For professionalism to be a living discourse between students and faculty, a truly longitudinal environment of awareness must take shape. Compartmentalization of professionalism education creates a null curriculum,11 suggesting to students that the subject is only viable in one or two disciplines of medical science. In contrast, “educational continuity,” a form of longitudinal, integrated learning, has been successful at producing physicians who are dedicated to professional and humanistic values.51–56
Recognizing opportunities to teach professionalism in basic science courses other than anatomy is an important first step in creating educational continuity. Educators in these other disciplines may extend the means by which anatomy educators have addressed professionalism challenges to cover these analogous “lost opportunities” in their courses. Others have called specifically for this increased emphasis on professionalism education in other basic science courses.57,58 Furthermore, creating this system of definitive professionalism education may be accomplished by developing regimented professionalism modules or by simply encouraging educators in the basic sciences to subjectively discuss the relevant professionalism issues throughout their respective courses. I personally believe that the latter will be more effective as professionalism education suffers under compartmentalization. Rather than relegating professionalism education to specified hours or days during the curriculum, I recommend that it be present throughout every lecture and laboratory session. Basic science educators then can follow the example of anatomy educators in assessing and providing feedback to students on their professionalism performance.59,60
Regardless of their method, educators in basic science courses should encourage students to avoid decontextualized memorization of scientific data and, instead, foster learning in preparation for practicing in a world where medicine interfaces with cultural norms, politics, and society. As many medical schools reform their curricula to emphasize medical professionalism education, these true opportunities for developing the physicians of tomorrow must not be overlooked. Students must remember that professionalism continues as they rinse their instruments, cover up the cadavers, and step out of the dissection lab into the real world of medical practice.
Acknowledgments: The author wishes to thank Drs. Frederic W. Hafferty, Wojciech Pawlina, David Hirsh, and David Stern for their invaluable support, advice, and suggestions.
Other disclosures: None.
Ethical approval: Not applicable.
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