There’s a saying in basketball: You can’t teach height. Of course, there are many things that would provide advantages in life that can’t be taught — competitiveness, intelligence, curiosity, creativity, stick-to-it-iveness. And we’ve all heard the one about old dogs and new tricks. Should medical professionalism be added to the list of unteachable subjects?
The medical profession, evidently, doesn’t think so. Almost every medical professional body in North America considers professionalism an essential topic and has mandated that it be taught in faculties of medicine. The Accreditation Council for Graduate Medical Education, responsible for accrediting residency and internship programs in the United States, considers it a core competency. Questions on professionalism appear on the Medical Council of Canada’s licensing exam, completed by all Canadian undergraduate medical students.
Some doctors, however, wonder if professionalism can really be learned in the classroom. Many of the qualities required to meet the professional ideals of medicine go far beyond biological know-how. Selflessness, empathy, benevolence — these aren’t exactly things one gleans from books. Medical professors can preach altruism, but no sermon can transform a student’s personality. The challenge of teaching a medical student to be a “good” doctor is, in some ways, akin to that of teaching an individual to be a “good” person. It is, in short, challenging indeed.
Still, professionalism in medicine is too important not to include in medical curricula, especially considering the prevailing opinion that doctors are less altruistic and more financially driven now than they once were, says Dr. Richard Cruess, a professor of surgery at McGill University’s Centre for Medical Education in Montréal, Quebec. Professionalism cannot be assumed. “It has to be taught,” says Cruess.
With his wife, Dr. Sylvia Cruess, he has long extolled the importance of teaching professionalism. Nearly two decades ago, they suggested that relevant topics include ethical codes governing physician conduct, the concept that being a professional is “not a right but a privilege,” and relevant material on professionalism from the fields of sociology, philosophy, economics, political science and medical ethics (BMJ 1997;315:1674-7).
“The profession is now diverse, as in almost every country doctors come from various cultural, ethnic, and economic backgrounds,” they wrote. “Though this represents an advance in terms of equity and fairness, it makes the transmission of common values more difficult and, in our opinion, requires explicit teaching of the role of both the healer and of the professional.”
Many others obviously agreed, and education on medical professionalism has flourished. But what are the teachings based on? And are they making a difference? Those questions remain difficult to answer.
“How do you measure degrees of benevolence and compassion? If it is so obvious to our profession what professionalism is, then why is it so difficult to teach it to medical students and residents?” Dr. Sze Wan Sit of Toronto, Ontario, wrote in a letter to Canadian Family Physician (www.cfp.ca/content/55/12/1183.short). “As a clinical teacher, I can testify that professionalism is no doubt one of the hardest points to evaluate and to remediate in our trainees.”
Indeed, when it comes to quality evidence supporting how best to teach and evaluate professionalism, there appears to be a rather short supply, according to Dr. Pier Bryden, a psychiatrist and the faculty lead in ethics and professionalism for undergraduate medical education at the University of Toronto in Ontario. “Currently, professionalism continues to receive some attention in training programs, primarily through faculty example and mentoring, yet there is no clear consensus or evidence base to inform best practice, teaching, and evaluation in this area,” Bryden and colleagues have suggested, noting that faculty involved in medical education claimed their “own lapses in professionalism and their failure to address these with one another posed the greatest barrier to teaching professionalism to trainees, given a perceived dominance of role modeling as its most influential teaching tool” (Acad Med 2010;85:1025-34).
But that doesn’t mean there is no value in at least introducing medical students to concepts of professionalism “rather than just throwing them out there and saying this is the reality of medicine,” says Bryden. Though mentoring may be more important, the classroom is an appropriate setting for exploring certain topics and for discussing how ethical principles should be applied in particular clinical scenarios. There may also be benefits to such activities as reflective writing and small-group discussion of clinical experiences. “You get the students to take a step back from the biomedical context and ask them to pause and reflect in a broader context about what they are doing,” says Bryden. “Do they experience more empathy? Does that change the way they interact with patients? That’s hard to measure, but it’s not a reason not to explore these topics.”
Another subject worthy of exploration, though largely ignored today, is medical history, says Bryden. “The history of medicine is part of our professionalism. It’s our elders’ legacy to us, their mistakes and their successes.”
The introduction of courses in humanities into medical curricula has also been driven by the professionalism movement. The theory is that evaluating literature or art will develop critical thinking skills and enable young doctors to better consider multiple perspectives on a topic — a patient’s perspective on a treatment, for instance. Though considered of dubious merit by some, the humanities are thought of by others as a good vehicle for making physicians more contemplative.
“Studying the humanities necessarily involves reflection. Individuals exposed to the humanities become more self-aware, more other-aware. They have better-honed critical analysis capacities. They can appreciate multiple coexisting and conflicting perspectives,” says Johanna Shapiro, director of the program in medical humanities and arts for the school of medicine at the University of California, Irvine. “Physicians are often more complex than we allow them to be. If you scratch the surface, you find they are curious and intrigued about other ways of understanding their patients.”
Many of the qualities required to uphold the professional ideals of medical practice — such as selflessness, empathy and benevolence — aren’t exactly things a physician can glean from a text book.
Image courtesy of © 2012 Thinkstock
One aspect of professionalism that has become of particular relevance to today’s medical students is appropriate use of social media. Though tech-savvy, medical students need to learn what is and isn’t appropriate to do on the Internet, even if their peers in other fields of study haven’t yet grown tired of uploading photos of eye-glazing, face-reddening, vodka-induced debauchery. “They need to be cognizant of online professionalism right from the beginning of their medical training,” says Dr. Kevin Pho, who practises internal medicine in Nashua, New Hampshire, and writes about social media on his website (kevinMD.com).
Some medical students haven’t learned that lesson. In one survey, 60% of 78 US medical schools reported unprofessional online behaviour by students (JAMA 2009;302:1309-15). The incidents included violations of patient confidentiality (13%), profanity (52%), discriminatory language (48%), depictions of intoxication (39%) and sexually suggestive material (38%). About two-thirds of schools reporting incidents issued warnings and three dismissed students for their transgressions.
“The formal professionalism curriculum should include a digital media component, which could include instruction on managing the ‘digital footprint,’ such as electing privacy settings on social networking sites and performing periodic Web searches of oneself,” states the study, led by Dr. Katherine Chretien, chief of the hospitalist section at the Washington DC VA [Veterans Affairs] Medical Center and an associate professor of medicine at George Washington University in Washington, DC.
A survey of medical students’ thoughts about online professionalism, also led by Chretien, revealed conflicting views (Acad Med 2010;85:S68-71). Though many were concerned about the risks and consequences of online behaviour, others resented the very idea of their schools attempting to control their lives. “Some said that, from 8 a.m. to 5 p.m., you can tell me what to do, but after that you can’t tell me what I can do, online or not,” says Chretien. “But some said they would never want someone to even see a picture of them holding a glass of wine.”
No matter how medical schools attempt to install professional values in future doctors — whether through encouraging exposure to art or discouraging overexposure on Facebook — it is important they make the attempt, says Michael Yeo, a philosophy professor at Laurentian University in Sudbury, Ontario. If nothing else, it’s good for public relations. Medical educators can truthfully profess to be concerned about turning out well-rounded doctors rather than those only comfortable nose-deep in medical textbooks. “It’s an assurance to the world: Don’t worry. We’ve got things in hand,” says Yeo. “We are teaching them not to just be competent, but also to be professionals.”