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Medical Humanities

Perspective: Medical Education in Medical Ethics and Humanities as the Foundation for Developing Medical Professionalism

Doukas, David J. MD; McCullough, Laurence B. PhD; Wear, Stephen PhD

Author Information
doi: 10.1097/ACM.0b013e318244728c

Abstract

Medical ethics and humanities teaching have become essential to teaching professionalism in medicine because the concept of professionalism is intrinsically scientific, clinical, ethical, and social. The Association of American Medical Colleges (AAMC) recognized the crucial role of such teaching as early as 1998 in a Medical School Objectives Project (MSOP) report, Learning Objectives for Medical Student Education: Guidelines for Medical Schools, which included a series of “must” statements about medical student education regarding character and ethical behavior (Box 1).1 Subsequent statements on ethics and professionalism and their role in the humanistic behavior of physicians from the Accreditation Council for Graduate Medical Education (ACGME), the Liaison Committee on Medical Education (LCME), the Joint Commission, and the United States Medical Licensing Examination (USMLE) and National Board of Medical Examiners (NBME) reinforce standards in these domains (Appendix 1).26

Box 1
Box 1:
Excerpts From the Association of American Medical Colleges Medical School Objectives Project Report I, Learning Objectives for Medical Student Education: Guidelines for Medical Schools, 1998*

More than 40 years after programs at such medical schools as Pennsylvania State University in Hershey and the University of Texas Medical Branch at Galveston began including medical ethics and humanities teaching in the undergraduate medical curriculum, it is time to critically appraise ethics and humanities medical educational methods and thereby make their role more explicit, robust, and accountable in the professional formation of medical students. The Project to Rebalance and Integrate Medical Education (PRIME) aims to enhance education in medical ethics and humanities by establishing benchmark standards for medical schools and residency training programs.

As a first step toward achieving the PRIME objective, we convened an expert panel of investigators to examine the role of medical ethics and humanities teaching in medical professionalism education. In this article we describe the selection of the panel members and the presentations and discussions that ensued. On behalf of the PRIME investigators, we present the recommendations that resulted from the first stage of this timely critical appraisal.

Professionalism, Post-Flexner

Abraham Flexner's7 1910 report to the Carnegie Foundation, with its central emphasis on the development of the physician–scientist, serves as a primary touchstone for PRIME. In addition to advocating improved teaching of basic and clinical sciences, Flexner argued for humanities education and the acquisition of humanistic skills.810 Over the past four decades, ethics and humanities educational programs have been introduced into the U.S. medical curriculum. In the past decade, these programs have been further informed by the ACGME's enormously influential “general competencies” language adopted in the Common Program Requirements.2 Professionalism grounds and justifies five of the ACGME's six core competencies (Patient Care, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice).11

The LCME requires education in “medical ethics, human values, and communication skills” with a learning environment promoting “adherence to ethical principles … observed, assessed, and reinforced through formal instructional efforts” (Appendix 1).3 The Joint Commission stresses how the general competencies “including interpersonal and communication skills and professionalism” must be part of the clinician's hospital credentialing.4 The NBME and USMLE examine “Doctor–Patient Communication, Ethics, and Professionalism.”5,6 The American Board of Internal Medicine underscored the importance of professionalism in its “Medical Professionalism in the New Millennium: A Physician Charter,” which has been promulgated internationally.12

In the seminal DeCamp Foundation report published 25 years ago,13 basic medical ethics skills were identified, but there has been no subsequent effort to undertake a comprehensive critical appraisal of medical ethics and humanities teaching in medical education. Most medical schools require medical ethics to be included in the curriculum,14 and many schools offer electives in the medical humanities, with some having required humanities curricula. National survey data indicate that medical ethics education in residency training programs is highly variable and often lacking.15,16 The first PRIME workshop (PRIME I) focused on how medical ethics and humanities achieve the goals and objectives of medical education, especially regarding professionalism.

Assembling the PRIME Panel

The authors (D.J.D., L.B.M., and S.W.) are the PRIME project leaders, and D.J.D. is the principal investigator on this two-year project to investigate how to effectively integrate medical ethics and humanities education into medical school and residency curricula. The foundations of PRIME lie in an earlier collaboration among the project leaders on an article about Abraham Flexner's essential role in promoting medical ethics and humanities in medical education, with an emphasis on art, ethics, history, and literature in medical education (List 1).9 Between 2010 and 2012, PRIME will have conducted two workshops (PRIME I, described here, and PRIME II, held in May 2011), followed by a national symposium in May 2012.

List 1 The Art and Culture of Medicine: Examples of Medical Humanities Elements
List 1 The Art and Culture of Medicine: Examples of Medical Humanities Elements:
List 1 The Art and Culture of Medicine: Examples of Medical Humanities Elements

For PRIME I, we used the method of the expert panel. The PRIME I investigators on this panel, who are listed at the end of this article, included educators in medical ethics and humanities from across the United States, representing the disciplines of ethics, history, literature, and the visual arts. Because of the synergistic relationship between medical ethics and law, we also included representation from health law. We selected representatives from the leadership of medical ethics and humanities programs as well as academic leadership. We tasked the PRIME I investigators with examining the “state of the art” of current medical ethics and humanities teaching (especially strengths and weaknesses), identifying challenges to integrating medical ethics and humanities teaching in the curriculum, and charting future directions. We selected the panel of PRIME I investigators using an iterative process based on four criteria:

  1. Association with a core discipline of the medical humanities;
  2. Experienced medical educators who had led development and implementation of a comprehensive curriculum in medical ethics and humanities at their home institution (based on both Medline citations and on their institutional Web page);
  3. A publication record in medical education; and,
  4. An institutional program (department, center, institute, or division) with a publication record in education.

We applied these criteria to choose educators who have made substantive contributions to the field and are very well positioned to influence ethics and humanities education reform in the future. Panelists were invited to participate and were not allowed to self-nominate or nominate others. We assembled a total of 15 PRIME experts, including the 3 project leaders and the invited 12 expert panelists. The resulting expert panel represented major medical ethics and humanities teaching programs and disciplines in geographically diverse programs in the United States.

The PRIME I Workshop, 2010

The PRIME I Workshop was convened May 7–8, 2010 in Louisville, Kentucky, sponsored by the Department of Family and Geriatric Medicine of the School of Medicine of the University of Louisville. The project leaders' previous publication9 served as the point of departure for the work of the PRIME I Workshop. In this article, the project leaders advanced a Flexner-based argument that medical ethics and humanities teaching should build on medical students' and residents' cultural and philosophic background to inform their role as professional physician–scientists. PRIME I investigators also used the definitions of medical ethics, narrative-based reasoning in literature, visual experience and reflection in the fine arts, and historical reasoning from this article (List 1). Additionally, we distributed several publications on medical ethics and humanities education to the investigators before PRIME I to stimulate conversation (list provided on request).

PRIME seeks to effect sustainable change in medical ethics and humanities education as they contribute to professionalism in medical education. To this end, PRIME I had three specific goals: (1) describe the major pedagogical goals of art, ethics, history, and literature as disciplines contributing to professional formation in medical education, (2) describe how the major pedagogical goals of art, ethics, history, and literature should be integrated with one another in medical education, and (3) describe how humanities education could be best integrated into preclinical and clinical medical education as well as into residency education.

The initial PRIME I session began with an overview by D.J.D. of changes in ethics and humanities education in the last century leading up to the recent emergence of the general competencies movement. The session concluded with a discussion of goals for both content and integration of art, ethics, history, and literature in the medical curriculum, and a discussion about integrating these topics with basic science, clinical medicine, and residency education. This opening session was followed by three working sessions, each of which included a presentation by one of the investigators from his or her disciplinary perspective with commentary from a colleague from another discipline to focus subsequent discussion. The first working session focused on the state of the art of medical education in art, ethics, history, and literature; the second on pedagogic methods and faculty development strategies in ethics and humanities education in medicine; and the third on curricular leadership from the perspective of the dean's office and the incoming president of the American Society for Bioethics and Humanities. A workshop summation then recapped the salient points raised by each session.

PRIME I Workshop proceedings were audio recorded (with participant permission) and subsequently transcribed. The project leaders analyzed the resulting transcript using inductive qualitative analysis (starting with the natural language expressions of participation and then organizing them into conceptually coherent and meaningful groups).17 Our goal was to identify the conceptualization of art, ethics, history, and literature and how they are taught within medical education, how new teaching modalities could enhance this education, and how ethics and humanities education could be integrated into medical education nationally. We gave specific consideration to school administration and national organizational support. For this analysis, project leaders read the transcripts multiple times and independently identified major themes and subthemes. The project leaders then discussed and negotiated these themes and subthemes to develop a master list of themes and subthemes that incorporated each investigator's input. Differences in interpretation were minimal and readily negotiated. The draft list of themes was then circulated and edited by all the PRIME investigators for validation.

Themes: Skills and Conduct, Support, and Clarity

In this section, we describe the three main themes that emerged in the analysis of the PRIME I discussion: (1) Medical education in ethics and humanities cultivates humanistic skills and professional conduct in physicians, (2) implementation of a comprehensive medical ethics and humanities curriculum in medical school and residency requires clear direction and academic support, and (3) implementation of medical ethics and humanities teaching should be based on an articulation of clear goals and end points that can be realistically assessed.

Humanistic skills and professional conduct

The first theme concerns the relationships between professionalism in medicine and the teaching of medical ethics and humanities as essential components in the development of medical students and residents as professional physicians. The first relationship is instrumental: Medical ethics and humanities teaching provides students and residents with a fund of knowledge and skills of reasoning, discernment, and judgment essential to sustainable professionalism in medicine. To this end, medical ethics and humanities build skill sets in visual observation, textual reading and interpretation, oral reasoning, and writing.

Study of the visual arts through art history and through production of art works (i.e., studio art) cultivates slow looking: the disciplined observation, interpretation, and reflection on visual details and on the overall picture essential to conducting, and interpreting the results of, physical examination. Art is multidisciplinary in execution and is mostly elective in medical schools.

The study and creation of creative literature (short stories, novels, poetry, drama) encourage humanism and critical thinking and serve as a vehicle to improve care, commitment, and self-care. Literature teaches that in any given situation there are multiple perspectives, making suspect the privileging of any one perspective (e.g., the physician's versus that of the patient or family), thereby helping to encourage humanism in physicians by eliciting and seeking to understand both the physician's and the patient's stories. Given that most diagnoses can be made based on a thorough history alone, the skills of eliciting and interpreting patients' stories are crucial for the preparation of medical professionals and the provision of proper health care. The use of literature in medicine courses is also largely elective.

Study of medical ethics (required at almost all medical schools, but not in many residency programs) develops skills of moral discernment, reasoning, and normative judgment in the care of patients. Students and residents come to learn that the physician–patient relationship, in its myriad biopsychosocial dimensions, is an intrinsically moral enterprise. This subtheme was rooted to the DeCamp report a quarter of a century ago that formulated a list of essential skills in ethics in the physician–patient relationship.13 Investigators noted that physicians also have responsibilities beyond the physician–patient dyad to the rest of society, especially when functioning as agents of social change. It is in this context that the synergy between medical ethics and health law becomes relevant.

Study of the history of medicine helps medical students and residents to stand in the past so that what we now take for granted, which is usually invisible, becomes visible and therefore open for critical appraisal. History also teaches that medicine is a profoundly social enterprise requiring that the social dimensions of medicine be identified and critically appraised. Again, as in art, history in medicine is largely elective.

The need for critical appraisal brought out a second relationship between professionalism in medicine and medical ethics and humanities teaching: Medical ethics and humanities teaching have an essential role to play in equipping medical students and residents with the tools to critically appraise the goals that the profession of medicine ought to pursue, ways the physician–patient relationship should be improved, and how the medical profession should understand and manage its complex relationship with society, especially through health policy and the institutions of self-government. Analytical decision making and critical self-reflection are end products of medical ethics and humanities education. These, in turn, promote critical appraisal of medicine. The result is physicians who should not be satisfied with the current fund of knowledge and skills. Medical ethics and humanities thereby contribute to the cultivation by students and residents of a lifelong commitment to medicine as a deliberate practice through transformative learning.18,19 The medical humanities foster habits of mind essential for self-assessment and virtuous comportment while promoting critical thinking regarding observation, introspection, reflection, and analysis.

Medical ethics and humanities challenge a narrowly construed, reductionist vision of the goals of medical education by teaching students to think expansively, thereby engaging in a critical appraisal of concepts such as medical professionalism. Critical appraisal skills help students ask how U.S. health care might be flawed as well as how it could be improved. Such skills also allow medical learners to become comfortable with uncertainty as a manageable rather than paralyzing challenge. Medical ethics and humanities teaching may even be viewed as a “subversive activity” because the learners ask: “What do we need to change, and from what to what? Why?” Such questions are not an arrogant threat to the status quo; rather, they are essential to lifelong learning and the ongoing evolution of knowledge, skills, and critical thinking that medical practice requires.

Clear direction and academic support

The PRIME I investigators emphasized the importance of thinking outside the confining box of time and hours in the curriculum. Medical ethics and humanities teaching, in the spirit of Flexner, should focus not only on what is lacking in learners but also on what each student brings to his or her medical school experience. At the same time, medical educators should assume that most students do not understand what professionalism in medicine means and requires of them. This includes especially one of the core values of professionalism: accountability achieved by evidence-based (basic and clinical sciences) and argument-based (medical ethics and humanities) reasoning. The goals of medical ethics and humanities teaching should be clearly articulated and explicitly linked to consensus goals of professionalism and, via external guidelines from LCME, ACGME, MSOP, USLME, etc., to those aspects of professionalism that lend themselves to reliable evidence-based quantitative and qualitative assessment (Box 1, Appendix 1).5,7 Investigators judged forging this link to be the key to achieving sustainable programs in medical ethics and humanities.

Medical schools will have varying faculty strengths and economics. PRIME I investigators called for the creation of a central, accessible depository of pedagogical resources to assist in implementation to support medical schools with less robust faculty resources. Funding ethics and humanities teaching for faculty development and support, as well as providing curricular time and space needs for seminar teaching, should be carefully considered, for academic leadership will rightly require clarity, specificity, and evaluation in these requests.

Clarity and assessment of goals and objectives

The goals and objectives of medical ethics and humanities teaching should be articulated clearly to conform to the discourse of AAMC, LCME, etc., they must be flexible regarding time and hours, and they must focus on goals and objectives expressed as assessable outcomes with implementable pedagogical tactics when such metrics are available and valid.5,7 Effective teaching of medical ethics and humanities requires flexibility—that is, multiple styles and resources with collaborative, interdisciplinary teaching methods that progress from normative education, to teaching and observing conduct, to inculcating values that promote humanistic behavior. Successful pedagogies address the challenges of lack of continuity in medical school, the hidden curriculum, and differences in adult learning styles.

PRIME I investigators called for medical humanities to become a required part of the medical curriculum, just as medical ethics is currently and as is called for by the AAMC. This curriculum should use interdisciplinary teaching and should assess appropriate outcomes that must be developed by ethics and humanities educators, with clear relevance for learners and educators in both preclinical and clinical settings, and having translational applicability to professional, humanistic patient care.

Rethinking “Skills”

PRIME I investigators emphasized the need for medical educators to appreciate the difference between ethics and humanities taught at the undergraduate, college, and university level and the medical ethics and humanities taught in medical schools. The justification for ethics and humanities teaching differs significantly based on the setting. General humanities education promotes the preparation of informed, critical thinkers for citizenship and leadership of the institutions of commerce, education, philanthropy, faith communities, and government. Medical humanities education aims at making the learner a better physician who has a lifelong commitment to medical professionalism.

Medical ethics and humanities promote this professional commitment by teaching two essential skill sets. The first set, patient-centered skills, enables students to become medical professionals and residents to excel as medical professionals. The discipline of ethics teaches learners to manage ethical dimensions of patient care responsibly. The discipline of literature teaches attention to narratives as learners reconstruct patient stories into medical histories that are necessary for accurate diagnosis and effective clinical management. The discipline of art teaches intense, detailed, and comprehensive observation. The discipline of history provides historical context that can help prevent a naïve view of progress that blinds learners to the limits of medicine. In their own ways, each of these disciplines promotes empathetic relationships with patients, which enhance compassion in medicine.

The second skill set, critical thinking skills, enables students and residents to critically appraise the concept and implementation of medical professionalism so that they can adapt it responsibly to the ambiguity and uncertainties of future medical care. Critical thinking skills contribute to performing the patient-centered skills required of the physician and can inform our understanding of how learners feel, as well as how they think, contributing to the education of the emotional intelligence of future physicians. Critical thinking skills address how the medical learner “processes” the healing experience in caring for patients, with an emphasis on how to observe, reflect, and analyze, thereby serving as the foundation to learning patient-centered skills.

PRIME I investigators concurred as an expert consensus panel that medical ethics and humanities teaching is essential for the cultivation of humanistic and critical thinking attitudes and skills that promote medical professionalism. The explicit linkage of medical ethics and humanities teaching to medical professionalism marks an important shift from the DeCamp Report, which emphasized ethics solely as a means toward developing essential clinical skills.8 Forging this link also positions medical ethics and humanities to contribute to the achievement of the educational mandates of professionalism by accreditation and testing organizations (Box 1, Appendix 1).

Next Steps for PRIME

The next steps for PRIME will address how medical education can better incorporate medical ethics and humanities through curriculum standardization and assessment. The 2011 PRIME II Workshop will again engage the expert panel approach and will also include leaders of AAMC, ACGME, and LCME. The participants will address the following four questions:

  1. Which medical school and residency learning objectives—especially, but not limited to, professionalism—do study in medical ethics and humanities support?
  2. How should study of medical ethics and humanities be improved so that it more effectively and demonstrably (i.e., using sound assessment means) contributes to the achievement of current medical school and residency learning objectives?
  3. How should medical school and residency learning objectives—especially, but not limited to, professionalism—be critically appraised?
  4. How should study of medical ethics and humanities be improved so that it more effectively and demonstrably contributes to the achievement of medical school and residency learning objectives that are defined/refined as a result of this critical appraisal?

These questions will be the framework for a comprehensive curriculum reform that will be presented at the National Conference on Medical Ethics and Humanities in Medical Education at the University of Louisville School of Medicine on May 10–11, 2012.20 This conference will be inclusive to all educators and administrators in medical education. The PRIME 2012 National Conference will be an open dialogue on how to formulate a national framework on integrating ethics and humanities into the required curricula in all U.S. medical schools and residency training programs. An outcomes-based agenda for future empirical research in medical education design will enable the programmatic educational research to demonstrate an evidence-based rationale for the inclusion of ethics and humanities in medical education.

We acknowledge that expert panels, such as the PRIME I investigators, can suffer from flawed selection criteria, resulting in the promotion of colleagues rather than an agenda, but we managed this limitation in PRIME I by adhering to rigorous selection criteria, based on multiple perspectives of scholarship and curriculum success. Although this method could overlook excellent work by a single person or small group in medical education, we plan to seek out these voices for the 2012 national conference with widely publicized efforts to encourage participation in the symposium.

Promoting Professionalism for the Future

Statements on education from AAMC, LCME, and ACGME agree that teaching medical ethics and humanities is essential to the goals of professional formation and development in medical education. The PRIME I expert panel concurred that medical ethics and humanities instruction in medical schools teaches essential elements of the ACGME general competencies (and other accreditation standards) regarding conduct and critical appraisal skills essential to developing the formation of medical students and residents into professional physicians. PRIME will continue to lead reform in medical ethics and humanities education that explicitly and measurably promotes the mastery of patient-centered skills and critical thinking skills in the coming generations of medical students and residents.

Acknowledgments:

The authors acknowledge the helpful assistance with data collection and collation by Andrew Gathof, and of workshop transcription by Brianne Nickel and Tobin Williamson.

References

1. Association of American Medical Colleges Medical School Objectives Project. Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Washington, DC: Association of American Medical Colleges; 1998.
2. Accreditation Council for Graduate Medical Education. General Competency and Assessment: Common Program Requirements. http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf. Accessed November 17, 2011.
3. Liaison Committee on Medical Education. Accreditation Standards. http://www.lcme.org/functions2011may.pdf. Accessed November 11, 2011.
4. The Joint Commission. Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards. http://www.jointcommission.org/assets/1/18/WP_Leadership_Standards.pdf. Accessed November 11, 2011.
5. National Board of Medical Examiners. Assessment of Professional Behaviors Program. http://www.nbme.org/schools/apb/index.html. Accessed November 11, 2011.
6. United States Medical Licensing Examination. Comprehensive Review of USMLE. Frequently asked questions: What are the “competencies? Are they all going to be assessed in USMLE? How? http://www.usmle.org/frequently-asked-questions/#cru. Accessed November 11, 2011.
7. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston, Mass: Updyke; 1910.
8. Flexner A. Medical Education: A Comparative Study. New York, NY: MacMillan; 1925.
9. Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85:318–323.
10. Doukas DJ, McCullough LB, Wear S. Re-visioning Flexner: Educating physicians to be clinical scientists and humanists. Am J Med. 2010;123:1155–1156.
11. Doukas DJ. Where is the virtue in professionalism? Camb Q Healthc Ethics. 2003;12:147–154.
12. Medical professionalism in the new millennium: A physician's charter. Project of the ABIM Foundation, ACP-ASIM Foundation and the European Federation of Internal Medicine. Ann Intern Med. 2002;136:243–246.
13. Culver CM, Clouser D, Gert B, et al.. Basic curricular goals in medical ethics. N Engl J Med. 1985;312:253–256.
14. Lehmann LS, Kasoff WS, Koch P, Federman DD. A survey of medical ethics education at U.S. and Canadian medical schools. Acad Med. 2004;79:682–689.
15. Downing MT, Way DP, Caniano DA. Results of a national survey on ethics education in general surgery residency programs. Am J Surg. 1997;174:364–368.
16. Mulvey HJ, Ogle-Jewett E, Cheng TL, et al.. Pediatric residency education. Pediatrics. 2000;106:323–329.
17. Miller WL, Crabtree BF. Primary care research: A multi-method typology and qualitative road map. In: Crabtree BR, Miller WL, eds. Doing Qualitative Research. Vol 3. Newbury Park, Calif: Sage Publications; 1992:3–28.
18. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406.
19. Mezirow J. Transformative learning: Theory to practice. In: Cranton P. Transformative Learning in Action: Insights From Practice. New Directions for Adult and Continuing Education. No. 74. San Francisco, Calif: Jossey-Bass; 1997.
20. The Project to Rebalance and Integrate Medical Education. A National Medical Education Conference on Ethics and Humanities. http://www.primemedicine.org/index/Home.html. Accessed November 22, 2011.
Appendix 1
Appendix 1:
Excerpts From Accreditation Standards Related to Professionalism

The Project to Rebalance and Integrate Medical Education (PRIME) Investigators:

Clarence Braddock, MD, MPH, Stanford School of Medicine; Howard Brody, MD, PhD, University of Texas Medical Branch at Galveston; Joseph Carrese, MD, MPH, Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University; Kelly Edwards, PhD, University of Washington School of Medicine; Joseph J. Fins, MD, Weill Cornell Medical College; Jack Freer, MD, SUNY–Buffalo; Michael Green, MD, MS, Penn State College of Medicine; Joel Katz, MD, Harvard University; Susan Lederer, PhD, University of Wisconsin Medical School; Janet Malek, PhD, East Carolina University; Johanna Shapiro, PhD, University of California–Irvine; and Katie Watson, JD, Northwestern University's Feinberg School of Medicine.

Funding/Support:

PRIME was supported by the Patrick and Edna Romanell Fund for Bioethics Pedagogy of the University at Buffalo.

Other disclosures:

Dr. Wear is the representative of the Patrick and Edna Romanell Fund for Bioethics Pedagogy of the University at Buffalo. The views of Dr. Fins are his own and do not represent the official views or policies of the American Society for Bioethics and Humanities.

Ethical approval:

Not applicable.

© 2012 Association of American Medical Colleges