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Step 2 Clinical Skills Exam Set for June 2004 Pipeline Programs: Looking Forward to Promote Diversity A Word From the President: Ten Unstoppable Trends Viewpoint: Educating for Professionalism in Medicine Portraits of Medical Education
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Viewpoint: Educating for Professionalism in Medicine
By any indicator - the appearance of new essays, research, curricula, feedback instruments, or innovation in certification and continued learning - in this past decade there has been a remarkable intensification of interest in professionalism in medicine. We can all speculate about why this is happening. I believe that it emerges from our profession's search for meaning and clarified values in distressing times. In this era we are less trusted by the public than we have been in decades, more expensive than ever, more aware of our error-proneness, more immersed in the "marketplace," and in more manifest competition with non-biomedical healers. The output of this decade of reexamination is to be found in many places. One that comes readily to hand at the AAMC is the Medical School Objectives Project. At the close of those deliberations, it was concluded that schools should prepare future physicians to be knowledgeable (in the scientific method and biomedicine), skillful (in communication, clinical skills, medical reasoning, and management of conditions), altruistic (avoiding conflict of interests and exhibiting respect, compassion, honesty, and ethical probity), and dutiful (attending to preventions and the health of populations, engaged in social action for health, and leading health systems). In many other similar statements on professionalism from individual essayists and professional organizations there is a remarkable degree of congruence about what I would consider to be the ideal attributes and behaviors of a virtuous person in medicine, attributes that reflect the foundational values of the profession. In the courses we teach and the essays we write, we are direct and articulate in positing our ideals: evidence-based medicine, therapeutic alliances, curing and healing, open-heartedness and open-mindedness, error avoidance, analytic minds, and altruism. In the real world of our lived experience, however, pursuit of these unalloyed ideals is fraught with ambiguity and difficulty. Even with "Grade A" evidence it is not clear what to do with the individual patient. Conflicts of interest are common. Every effective therapy also risks harm. Compromising with circumstanceSome situations seem to demand the "often wrong, but never uncertain" doctor. While we seek to be error-free, we know that we're mistake-prone. Knee-jerk reasoning is a way of life, and health economists remind us that homo economicus is a fair caricature of the physician. None of these situations are wholly avoidable, but our literal silence about this "compromise struck with circumstance" is regrettable, especially in our role as educators. And how are we faring as medical educators in preparing future physicians for professional roles in our complicated world? I would conclude that the "formative arc" of education today is strong on the acquisition of technical knowledge and weak-to-negative on the acquisition of values and moral formation. While preparing successfully to pass tests of knowledge, our students measurably move from being open-minded and curious to test-driven and minimalistic, from open-hearted and idealistic to self-centered and well-defended, and from altruistic to cynical. In the course of their educational experience with us, they also move from taking notes and focusing on the explicit curriculum (what we say) to learning most from what we do. Here, then, is the greatest challenge of educating for professionalism. If we wish to change our students' preparation for their careers, we ourselves will need to change. What is the action agenda? After a recent review and approval by its Executive Council, the AAMC Division of Medical Education is distributing a document I authored, A Flag in the Wind: Educating for Professionalism in Medicine, which outlines many specific actions that might be taken to redirect and improve the educational environment for professional development. The options emphasize key institutional roles and accountabilities, organizational performance and management, trainee/physician/program performance and feedback, and making explicit use of the hidden curriculum. All activities require a heightened focus on seminal events, becoming articulate about our professional values in situations that invoke them (a second prime directive - primum non tacere - Be not silent!), and joining forces with our colleagues in other health disciplines. While this kind of organizational and professional change would be difficult in any era, current forces for educational change in licensure, certification, accreditation, and performance evaluation are as well aligned for this work as they may ever be. Ironically, while professional distress is discomforting, it does also produce a certain fluidity and capacity for change. The worst of times might be the best of times for progress in educating for professionalism. |
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