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What Community-Based Education Can Teach Tomorrow's Doctors

Whitcomb, Michael E. MD

From the Editor

Several years ago, a watershed document on professionalism in medicine was published by the American Board of Internal Medicine Foundation in collaboration with two other major physicians’ organizations.* That document, “Medical Professionalism in the New Millennium: a Physician Charter,”1 sets forth three fundamental principles and a set of definitive professional responsibilities that physicians should carry out to maintain the integrity of the social contract that exists between medicine and society. Numerous professional organizations in this country and abroad, representing almost all of the medical specialties, have endorsed the Charter.

Among other things, the Charter makes clear that the medical profession has a responsibility “to define and organize the educational and standard-setting processes for current and future members.” Indeed, the responsibility to determine how the next generation of physicians will be educated is one the profession has taken very seriously. The various medical education reforms that were adopted during the past century reflect a strong commitment to this particular duty.

Some outside the profession, who are concerned about the quality of medical education, argue that the reforms have been inadequate. At the same time, some within the profession argue that they were too far-reaching. Regardless, there can be little doubt that members of the profession have made a concerted effort over the years, in keeping with their professional responsibilities, to continuously improve the education of the next generation of physicians. Having said that, I think we all need to remember that the battle is far from won. The profession will soon be severely challenged to adopt the kind of educational reforms needed to adequately prepare physicians to provide the high-quality care the public has every right to expect. In my opinion, the privileged status of the medical profession will be greatly affected by how well this challenge is met.

During the coming months, I will return to this theme regularly in these pages because I think that the members of the medical education community and the leaders of medical schools and teaching hospitals must proactively address the need for medical education reform. I hope that my editorial comments will help stimulate debate about some of the critical issues that must be confronted if the profession is to meet its responsibility to produce physicians who can truly serve the needs of the public.

In this editorial, I want to focus on one particular aspect of this challenge—that is, how we should educate future physicians to manifest what many have referred to as civic professionalism. The Charter makes reference to this in noting that medical professionalism “entails not only physicians’ personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society.” Some of the articles in this month's journal provide insight into the challenge this issue presents to the academic medicine community.

Eggly and her colleagues put the challenge in perspective. They report the results of a study they undertook to gain additional insight into the observation made by others that physicians in training—both medical students and residents—observe and experience professional behaviors that are often inconsistent with the ideal standards set forth by the physician community in documents such as the Charter. Using that document as a framework, they analyzed the perceptions that residents in several disciplines had about medical professionalism based on their experiences during medical school and the first year of their residencies. The residents were asked three questions designed to explore their impressions of the meaning of medical professionalism. A key finding of the study is that there was “little convergence between the categories of ideal professional behavior proposed by the Charter and the reported experiences of interns during their medical training.” And it is particularly noteworthy that they almost entirely ignored the principles of professionalism related to social, political, or economic issues.

The article by O'Toole and his colleagues suggests one way to address this deficit. They describe how a community-based professionalism curriculum conducted as part of a national demonstration project affected medical students’ perceptions about medical professionalism. Their findings suggest that community-based experiences can enhance the likelihood that physicians in training will develop appropriate and lasting attitudes about their professional responsibilities to the communities in which they live and practice. The authors observe that since medical schools have an important role to play in fostering appropriate professional attitudes and values in their students, schools need to give all their students opportunities to participate in community-based experiences designed to expose them to the responsibilities of civic professionalism. Needless to say, the same holds true for residency programs. The challenge for medical schools and residency programs is how to accomplish this reform.

Another possible approach is reported by Meyer and her colleagues. These authors describe a model of a community–academic partnership that allows pediatric residents to gain an appreciation of the context in which care is provided by having them participate in activities conducted by community agencies. The residents develop an understanding of the social and cultural determinants of health and how community agencies can serve a role in promoting health in their communities. And Davidson and Waddell offer a third approach in their article about an interdisciplinary health professions course based in the community.

The articles by Steiner and colleagues and by Calleson and colleagues address a critically important issue related to various kinds of community-based education. There are at least some reasons to believe that the impact of community-based educational experiences might be enhanced if students and residents saw faculty members from their institutions engaged in those experiences in some way. The visibility of faculty in the educational experiences might impress the learners that the institutions responsible for their education truly value community-based educational experiences. But to accomplish this, medical schools and teaching hospitals must be willing to recognize that faculty members’ participation in community-based activities can contribute to the institutions’ academic mission. In the same vein, the institutions must accept the notion that there is such as a thing as community-based scholarship. Both articles offer insight into how these goals might be accomplished.

Taken together, these six articles make an important point: If the medical education community believes that it is important for physicians in training to develop attitudes and values consistent with all of the professional responsibilities physicians should ascribe to, as set forth in the Charter, those responsible for undergraduate and graduate medical education programs must provide opportunities for their students to have community-based educational experiences. Doing so will allow medical students and residents to observe and truly understand the health care needs of communities, and how members of the medical profession can contribute to addressing those needs. For that to occur optimally, faculty members must be engaged in those experiences. And for them to do so in sufficient numbers, medical schools and residency programs must recognize the value of community-based scholarship. This will be a major challenge to those holding leadership positions in academic medicine, one that must be met if the principles of medical professionalism are to have meaning to tomorrow's doctors.

Michael E. Whitcomb, MD

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1 ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine Foundation. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–46.

*The American College of Physicians Foundation and the European Federation of Internal Medicine.
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