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Invited Commentaries

Trustworthiness and Professionalism in Academic Medicine

McCullough, Laurence B. PhD; Coverdale, John H. MD, MEd; Chervenak, Frank A. MD, MMM

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doi: 10.1097/ACM.0000000000003248
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Abstract

The primary mission of academic medicine at all levels is to produce physicians with a sustained commitment to fulfilling the aims and obligations of the profession of medicine. Becoming trustworthy as a member of the profession is essential to this lifelong commitment. The previous editor-in-chief of Academic Medicine, David Sklar, launched an exceptional series of “New Conversations” on trust in health care and health professions education.1 These articles addressed a wide range of issues including the building of trust in the physician–patient2–5 and student–teacher relationships,3,6,7 the professional relationship among physicians,4 and the relationship between physicians and health care organizations.8,9 These articles support the conviction that trust is essential for professional clinical practice and for medical education.

Our aim in this Invited Commentary is pedagogical: we provide an account of the professional virtue of trustworthiness that medical educators and academic leaders can use in supporting learners to become and remain trustworthy physicians. To achieve this goal, we identify the 2 components of trustworthiness: patients’ intellectual trust and moral trust in their physicians. We will base our account on the ethical concept of medicine as a profession, which was invented in the 18th century precisely as an antidote to the widespread, corrosive distrust of physicians that had existed for centuries. We then propose how to teach the professional virtue of trustworthiness and assess the impact of such teaching in a professionalism curriculum in undergraduate and graduate medical education.

Trustworthiness in 18th-Century Professional Ethics in Medicine

John Gregory (1724–1773) of Scotland and Thomas Percival (1740–1804) of England have been credited with inventing the ethical concept of medicine as a profession.10–14 They were the first to identify the 3 commitments that define this concept: physicians should become and remain scientifically and clinically competent; physicians should make the protection and promotion of the patient’s health-related interests their primary concern and motivation and keep individual self-interest systematically secondary; and physicians should make the protection and promotion of the patient’s health-related interests their primary concern and motivation and keep group or guild self-interest systematically secondary.15–17

Gregory and Percival were both self-conscious reformers who set out to change medicine from its centuries-long history of entrepreneurial, not professional, practice. The influence of Gregory’s professional ethics in medicine is apparent, with translations of his work into French,18 German,19 Italian,20 and Spanish21,22 appearing within 3 decades of their original publication, as well as subsequent editions in the United States.23 Benjamin Rush (1746–1813) attended Gregory’s ethics lectures at the medical school at the University of Edinburgh. He subsequently adapted Gregory’s work in his own book on medical ethics and his teaching at the University of Pennsylvania medical school.24 Gregory’s Lectures and Percival’s Medical Ethics appeared in later editions in Britain in the 19th century. Their professional ethics in medicine have become available in contemporary editions.15,25 Gregory and Percival worked to create a professional ethics for medicine that was transcultural, transnational, and transreligious. Inasmuch as physicians around the world live out the 3 commitments that define the ethical concept of medicine as a profession, Gregory and Percival’s influence persists.10–12

The 2 Components of Trustworthiness

Intellectual trust

Gregory and Percival invented the first commitment of medicine as a profession, to scientific and clinical excellence, in response to the bewildering array of medical theories and practitioners of their day. At that time, there were almost as many theories of disease and remedies, including medications containing opium (without accurate disclosure), as there were practitioners. There were allopaths, homeopaths, naturopaths, botanists, female midwives (in fierce competition with physicians known as “man-midwives,” the forerunners of obstetricians), surgeons, apothecaries, veterinarians (in rural villages), and a host of irregulars, known less charitably as “quacks.” Anyone could call himself or herself a healer, in the absence of licensing by the state. There was no common clinical language, as there is now, based on the science of physiology, which Herman Boerhaave (1668–1738) had begun to teach in Leiden in the Netherlands.

During this time, there was no established educational pathway in the new medical schools of the time and no external accreditors. Not all students received degrees. Students could take several courses or the full course of study. They could also study at more than one medical school without completing the course of study in any of them and still call themselves physicians. Some physicians received MD degrees without having attended the medical school that awarded them. Some impecunious medical schools even sold MD degrees.14

This unclear and chaotic situation had a direct impact on how the sick experienced illness and injury. Dorothy and Roy Porter have documented, from 18th-century letters and diaries, that the sick had little or no confidence that practitioners knew what they were talking about or knew what they were doing. In the absence of such confidence, distrust was rampant.26 The sick self-diagnosed and self-treated (“self-physicking” this practice was called) and sought medical help only when they did not improve. The wealthy hired practitioners for the household. The “worthy poor,” or the sick working poor, went to the Royal Infirmaries.14 The situation in the British colonies of what is now the eastern seaboard of what later became the United States was much the same.27

Gregory and Percival were imbued with the commitment to improving all aspects of life, a commitment that defined the Scottish and English enlightenments and was informed by the philosophy of science and philosophy of medicine of Francis Bacon (1561–1616). Bacon insisted that science and therefore scientific medicine be based on “experience.” By this he emphatically did not mean a physician’s personal experience, which he, correctly, understood to be riddled with bias. Instead, “experience” meant the carefully observed and analyzed results of natural experiments (e.g., the natural history of gangrene of the foot) and of controlled experiments (e.g., splitting a compound into its several components and testing each separately to identify which is producing observed effects of the compound). This approach was a nascent form of what we now call evidence-based medicine.14

Eighteenth-century professional ethics in medicine is crucial for our understanding of the concept of trust in physicians in its intellectual dimensions: (1) the confidence of patients that physicians are competent to diagnose and manage patients’ conditions, disabilities, diseases, and injuries based on rigorous clinical reasoning, especially evidence-based reasoning, and (2) the reliance of patients on physician’s clinical competence.

Moral trust

Sick people during Gregory and Percival’s time also worried that physicians, surgeons, and other practitioners were solely motivated by the desire to line their pockets with high fees or by the desire for power over the sick that physicians and surgeons gained for the first time in the regimented environment of the Royal Infirmaries.14,15,26 Physicians and surgeons who volunteered their services staffed the Infirmaries. Some of these physicians also promoted themselves as leading investigators by declaring patients incurable and then performing their favored experiments on them—with none of the apparatus of required, prospective research oversight that we now take for granted. Gregory condemned this practice as unprofessional.15

Eighteenth-century professional ethics in medicine is crucial for our understanding of the concept of trust in physicians in its moral dimensions: (1) the justified confidence of patients that physicians and their health care organizations are primarily committed to the protection and promotion of the health-related interests of patients and to keeping individual, group, and organizational self-interest systematically secondary, and (2) the reliance of patients on this commitment.

Teaching and Assessing the Professional Virtue of Trustworthiness

Irby and Hamstra identified 3 professionalism frameworks: virtues-based professionalism, behavior-based professionalism, and professional identity formation.28 We propose an approach to teaching and assessing the professional virtue of trustworthiness by reference to each of these frameworks.

Curricular content

Irby and Hamstra’s virtues-based framework calls for learners to develop moral character and reasoning, and the habits, or virtues, that exhibit professionalism.28 A recent systematic review of the few randomized controlled or controlled nonrandomized trials of ethics teaching in undergraduate and graduate medical education found that the heterogeneity of these studies does not support a strong conclusion about the effectiveness of such instruction.29 However, it is widely accepted that the foundation for effective ethics teaching is precision of thought and speech. To support development of precision of thought and speech, teaching the professional virtues should focus first on mastery of the conceptual vocabulary of trustworthiness: intellectual and moral trust, as defined above. Mastery of this simple vocabulary initiates the process of internalizing professional values and thereby empowers all subsequent learning in professionalism and trustworthiness.

Berger and colleagues’ systematic review of teaching professionalism in postgraduate medical education identifies key competencies, centering on commitments to patients, society, and the profession.30 Teaching these competencies creates a pedagogical opportunity to explain the professional virtue of trustworthiness. For example, the commitment to excellence in patient care should be understood by learners to elicit intellectual trust from patients. So too, exhibiting appropriate professional values and behaviors and responding to unprofessional behaviors create conditions for moral trust from patients. Berger and colleagues’ systematic review demonstrated that many published professionalism curricula in postgraduate medical education are effective.30 Berger and colleagues also emphasized that there are multiple formats for effectively teaching professionalism.30 Didactics and online materials can be used to introduce learners to the 2 components of trustworthiness. Small-group teaching and reflective exercises can focus learners on identifying behaviors that elicit or undermine trustworthiness. Ancient wisdom underscores the critical importance of role modeling the professional virtues. Faculty should endeavor to role model intellectual and moral trust in how they respect and treat patients and in their relationships with learners. Faculty should also be vigilant to counter the informal or “hidden” curriculum when it has an adverse impact on professional formation of learners as trustworthy.

Fragkos and Crampton systematically reviewed randomized controlled trials on the effectiveness of teaching empathy to medical students and found that overall empathy interventions in medical student learning are effective.31 Teaching empathy can be augmented by introducing the concept of earning moral trust from patients as an important goal of being an empathic doctor. Making the concept of moral trust explicit provides a precise direction for empathy, preventing vagueness about this essential professional disposition.

Assessment

Assessment should be guided by Irby and Hamstra’s behavior-based framework.28 Assessing a pedagogy on trustworthiness begins with identifying the behaviors of learners related to trustworthiness. These include behaviors that educators will interpret as indicative of progressive mastery of trustworthiness, as well as behaviors that are inconsistent with, and therefore threaten to undermine, trustworthiness. Behaviors that express intellectual trust include a consistent reliance on evidence-based reasoning on teaching rounds and in explaining care plans to patients and parents (e.g., why evidence does not support use of antibiotics to treat uncomplicated otitis media in a 5-year-old). Behaviors that express moral trust include consistent respect for patients (e.g., addressing a new patient by his or her last name, an especially important consideration for older African Americans who may have experienced the use of first names without permission as a means of denigration and social control). Behaviors that are inconsistent with moral trust include involving students in patient care without the patient’s knowledge or permission (e.g., vaginal examination during surgery). This practice is invisible to the patient but not to the learner, whose professional moral development is distorted. Patients’ complaints should also be considered, especially when they express concern about disrespect or outright distrust.32

Educators should design assessment of these and other observable behaviors that will count as evidence for faculty to measure learners’ mastery of trustworthiness, erosion of trustworthiness, and loss of trustworthiness.33 These behaviors should be articulated in increasing, observable, and integrated levels of mastery from the first patient encounters in undergraduate medical education through the completion of residency and fellowship.34 These measures should be stated in curricular materials.

Professional formation

Irby and Hamstra’s third framework describes identity formation of learners and medical professionals.28 The ethical obligation to maintain the profession of medicine as a public trust begins the first day of medical school, an obligation that presupposes years of character formation that medical educators and academic leaders should continue explicitly as professional character formation.35,36 The stakes are high: If too many learners and physicians abandon the commitment to the ethical concept of medicine, the profession of medicine will erode from within. More optimistically, when physicians make and sustain their commitment to the ethical concept of medicine, they earn patients’ intellectual and moral trust by exhibiting the professional virtue of trustworthiness. Professional virtues such as trustworthiness—as well as integrity, humility, compassion, self-effacement, and self-sacrifice—become transformational: they shape the physician’s character. Professional virtues have this formative effect on the character of learners because trustworthiness and the other professional virtues are grounded in the ethical concept of medicine as a profession.

From the perspective of trustworthiness and the other professional virtues, medical educators and academic leaders should take responsibility for the professional character formation of all learners: medical students, residents, fellows, and colleagues alike. Medical educators and academic leaders should not hesitate to embrace this role and to be assiduous in discharging its obligations. This is demanding but crucial work.

Medical educators and academic leaders share the responsibility to create and sustain an organizational culture of professionalism. Organizational culture includes the mission and values of an academic institution, what it expects and discourages, and what it tolerates—especially what it tolerates that should not be tolerated. For example, an organizational culture that emphasizes faculty productivity over teaching and academic service risks creating an alienating organizational culture in which faculty come to think of themselves as factory workers and not professionals37 or reducing faculty to product salesmen and saleswomen.38 The pedagogical result is to tolerate what should never be tolerated: putting before learners role models of merely transactional and not professional virtues, behavior, and identity.5 Medical educators and academic leaders periodically should lead a critical self-appraisal of the organizational culture of their academic institutions and prioritize—or reprioritize as necessary—teaching, mentoring, collegiality, research, and care of patients.39 Since challenges to physician well-being are widespread, physician well-being should be addressed by proactively supporting meaningful engagement, vitality, and fulfillment in medicine.40

Some of the behaviors that evidence trustworthiness may be largely invisible to patients, such as accountability to colleagues for adherence to evidence-based guidelines (intellectual trust) and preventing upcoding to increase revenue (moral trust). Monitoring by medical educators and academic leaders and self-monitoring by learners are essential for making trustworthiness a professional virtue on which patients can routinely rely.

This process of monitoring takes on greater significance when we take seriously a lesson from the above history: trustworthiness is not a timeless concept that will remain intact despite deviations from its requirements of intellectual and moral trust. This is because the ethical concept of medicine is a relatively young concept from the perspective of the history of medicine. Trustworthiness is a function of the commitment of medical educators, academic leaders, and learners to the ethical concept of medicine as a profession. As such, it is indeed fragile because it is vulnerable to deviations from its requirements.

Conclusion

Medical educators and academic leaders should sustain learners, especially medical students and residents, in the progressive mastery of the conceptual vocabulary of trustworthiness and in their behavior and identity formation as increasingly trustworthy learners and providers of patient care. All components of the formal professionalism curriculum should be designed to achieve these pedagogical goals. Because the hidden curriculum can subvert a formal professionalism curriculum, the potential for adverse impact of the hidden curriculum should be identified and prevented. The assessment by learners of their educational experiences in both the formal and hidden curricula should be taken seriously. Medical educators and academic leaders should follow up with a critical appraisal of learners’ assessments and act on them fairly, nonpunitively, and effectively. The goal of teaching trustworthiness should be to create and sustain a professional academic culture that is transparent, respectful, accountable, and committed to the effective professional formation of learners.

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