Educating For Professionalism: Creating A Culture Of Humanism In Medical Education

by Delese Wear, Janet Bickel, Jordan J. Cohen

Overview

In their desire to improve medical professionalism within the world of academic medicine, editors Delese Wear and Janet Bickel have assembled thirteen thought-provoking essays that elucidate the many facets of teaching, valuing, and maintaining medical professionalism in the middle of the myriad challenges facing medicine at the dawn of the twenty-first century.
     The collection traces how the values of altruism and service influence not only mission statements and admission policies but also the content of medical school ethics courses, student-led task forces, and mentoring programs, along with larger environmental  issues in medical schools and the communities they serve.

Product Details

ISBN-13:	9781587296970
Publisher:	University of Iowa Press
Publication date:	07/15/2008
Edition description:	New Edition
Pages:	236
Product dimensions:	6.00(w) x 8.90(h) x 0.70(d)

About the Author

Delese Wear teaches at the Northeastern Ohio Universities College of Medicine. She is author of Privilege in the Medical Academy: A Feminist Examines Gender, Race, and Power and Professionalism in Medicine: Critical Perspectives, and was the editor Journal of Medical Humanities from 1994 to 2007. Following 25 years in positions of  increasing national leadership at the Association of American Medical Colleges, Janet Bickel started her own business as a career and leadership development coach and consultant. She is also an adjunct assistant professor of medical education at George Washington University School of Medicine and a member of the Executive Leadership in Academic Medicine [ELAM] Consultation Alliance.

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Educating for Professionalism Creating a Culture of Humanism in Medical Education
UNIVERSITY OF IOWA PRESS Copyright © 2000 University of Iowa Press
All right reserved.
ISBN: 978-0-87745-741-1



Chapter One STANLEY JOEL REISER

The Moral Order of the Medical School

The moral order of the medical school is created by the interactions among the members of its community, and by the policies and pronouncements it undertakes in the course of institutional governance. The ethical influence of these activities on the people who learn and work in the institution is as profound as that of courses and the other kinds of formal ethical discourse it sponsors. This chapter examines the moral influence of institutional relationships and policies on the life of the medical school and the professional development of its students. In medical education, the medium is indeed the message.

Interactions between Students and Personnel

When teachers present the most pertinent aspects of their field to students and strive to secure the personal involvement of students in the tasks of learning, they fulfill critical requirements of their profession. But what teachers themselves do with their knowledge and lives is educationally and morally significant. Do they serve patients without the means to pay for health care through work in community clinics? Do they help the public understand the reach and limits of their fields through popular articles, editorials, or talks? Do they express disagreements with colleagues respectfully? Do they treat staff and professional colleagues beneath and above them in the school's hierarchy with equal dignity? Do they balance their commitments to professional duties and family responsibilities well?

"The Physician," an essay focused on ethics in the Hippocratic writings, depicts the educational importance of the doctor's character and actions. It begins: "The dignity of a physician requires that he should look healthy ... for the common crowd consider those who are not of this excellent bodily condition to be unable to take care of others.... [He should have] a great regularity of life, since thereby his reputation will be greatly enhanced; he must be a gentleman in character, and being thus he must be grave and kind to all" (Hippocrates, 1923b, p. 311). These admonitions do not address patient care itself, but they are highly significant for it, because they predict what kind of care a doctor will give. Who doctors are outside of the medical relationship anticipates who they are likely to be within it. By analogy, what professors do with their knowledge beyond the classroom influences the learning that takes place in it. Students learn to trust their professors from seeing them not just hone, but live, their arguments.

Teachers also influence students by caring about and respecting them. All teaching involves the simultaneous transmission of two lessons: one is a lesson about theory or technique - why nature or artifact is what it is, or how to do something; the second is a lesson about ethics - the teacher's response to the student's efforts to learn and grow. The first lesson teaches students about intellectual constructs and technological reach and limits; the second instructs them about the exercise of power and authority and the meaning of human dignity. Too often teachers focus on the first lesson, either unaware of or unsympathetic to the second. But diminishing the significance of concern and respect in human relationships may be by far the most powerful lesson that teachers leave behind.

The clinic is a particular generator of problems associated with unintended messages. The time demands on clinical teachers, usually residents, often do not allow for much more than just showing students "how to do it." The difficulty for students of using a given technique on frightened, vulnerable, and sometimes inarticulate patients can be lost or ignored by instructors, along with the effect of insensitive criticism of students' efforts should they fail to apply it adequately. All lessons faculty give students affect multiple aspects of their lives, from their immediate development to their future relationships with colleagues and patients.

An exchange of obligations between student and teacher is at the heart of the Hippocratic oath, which creates the concept of profession in Western medicine (Hippocrates, 1923a, pp. 299-301). After the introductory sentence of the oath, which focuses on the solemnity of the act of taking it and the significance of the obligations assumed by those who swear to it, comes a section on the student-teacher relationship. Students are asked to share income with teachers if they are needy, to educate without fee the sons of teachers who wish to learn medicine, and to hold teachers as equal to parents! Such extraordinary commitments emphasize ethical reciprocity as central to the association of students and teachers. The weighty return expected of a student implies a weighty commitment by the teacher in the initial learning process, and a continuing relationship once this stage is over. The student and teacher develop a lifelong bond of care and concern.

Further, the student-teacher relationship prefigures the student-patient relationship. Students first learn about the use of authority in medicine from the faculty - how those with power and knowledge treat those who lack it. Albert Schweitzer is credited with saying, "Example is not the main thing in influencing others, it is the only thing" (Maudsley, 1999, p. 144). Thus medical educators must help students understand the complexities of relationships with their teachers, recognize that they should not treat students as passive vehicles into whom knowledge is poured, and learn that the teaching relationship carries lessons which influence the human as well as the technical side of the professionals their students become.

How can students help create the feelings and duties of reciprocity found in the oath and thus elevate and bring harmony into their learning relationships? Students must have a commitment to know the subjects they study - not only acquiring basic facts but also appreciating possibilities and shortcomings. Here, students have an advantage over their teachers. Faculty, immersed for years in the normative views of their discipline and writing articles to extend this knowledge, are usually less and less able or willing to see the flaws and inconsistencies potentially visible to new eyes. If faculty are open to it, and students are inclined to question the assumptions of a field, this kind of engagement can create an excitement and mutuality in the learning relationship.

Students should also recognize the ethical issues confronting them in their daily learning. For example, students coming to the bedside of a patient to develop skills in taking a history, doing a physical exam, or drawing blood should acknowledge their limits to patients and follow the "do no harm" ethic. Students must ask patients for permission to learn on them, and patients must give their consent. When students feel they need the help of their teachers in the face of a possible harm to a patient, they should not be afraid to ask for it. Students should be supported when they make the hard choice of seeking assistance. Since most students are concerned about appearing unprepared and indecisive, or challenging the norm of self-reliance with such requests, faculty should come to their aid. Faculty should explicitly tell students that they encourage such requests; that they do not wish learning to be purchased at the expense of harm. Nor should they teach students the lesson that silence is appropriate when the possibility of danger to an innocent and vulnerable person exists. It is just as important for students to understand and be guided by such ethical precepts in learning as it will be later in practice. When students minimize or disregard the ethics of learning, they hamper their own progress toward becoming ethical clinicians.

* * *

The learning environment of the medical school is shaped not only by its academicians but also by the multitude of other employees, generally referred to as "staff." The staff are the physiological engines of the institution. They open its doors as well as close and guard them; they direct the flow of materials and information to its units; they give help and receive complaints; they provide aid and take tuition; they make appointments, keep records, maintain infrastructure, and repair damage; they organize and oversee the complex fiscal and administrative systems that make the institution run. Students encounter the staff as much as if not more than their professors. What is their place in the educational experience of students?

The staff is the real community of the institution. They tend always to be there, and in the same place. Staff and their spaces are like the residents in neighborhood stores and houses. I once asked a group of about three hundred employees at my school, "What is your job?" They answered lab technician, employee counselor, internal audit, department secretary, security guard, and so forth. I suggested to them that all these were things they did, but that their job was to create an institutional environment of respect, consideration, and help in a collective effort to educate and develop humane health care professionals. Each staff member had a specific technical task to fulfill to keep the place running, but they all were bound together in a common educative mission. From doing case rounds with staff concerning issues of institutional culture and governance, I can affirm that staff feel themselves elevated in standing and significance when they recognize they have a role in the education of students.

How can the staff be helped to exercise this role? Institutional recognition, encouragement, and validation that learning in medical school has two distinct and coequal dimensions - a technical and an ethical component - are essential. The staff cannot participate directly in the teaching of technical skills but it does participate in the teaching of ethics. In their interactions with students, the staff show by example how to exercise power and authority. Department secretaries as guardians of appointments and access to professors; financial staff in charge of assuring that student monetary obligations are met or providing assistance to meet them; security guards whose keys provide access to facilities - all of them have opportunities to teach students about treating people with respect and dignity; how to show kindness, tolerance, and patience; how to cope with failure; and how to handle success. This cross-section of the real-world community in which the medical student will work and provide care has an enormous potential to educate. Ideally, the medical school should give staff the charge and help to do it, by formally declaring and encouraging the staff in this role, by developing literature and seminars for them on these issues, and by acknowledging in public statements and in salaries particularly meritorious staff-student relationships.

Policies and Pronouncements of the Medical School

The medical school has a moral character independent of, though influenced by, the moral character of those who live in it. The medical school creates its character by the choices and decisions it makes over time as an institution. These actions, which tend to be based on its dominant traditions and values, define the institution to both its members and the public.

A school's history has a major influence on its institutional identity. On the walls of its most significant spaces hang portraits of founders, benefactors, administrators, and professors, and photographs of classes, buildings, and notable events. These displays indicate the relationship of the past to the present. Past accomplishments modulate into school traditions, which establish an identity in the present as elements of the school's reputation. The identity of an institution also derives from the actions of the people presently there. For example, as Norma Wagoner writes in part 2, medical schools all over the country have recently established "white coat" ceremonies, in which first- or second-year students receive this symbol of the medical profession in a ceremony invoking compassion and humility. In addition to such practices, the policies and procedures of medical schools establish or maintain a particular identity.

The collective effect of these events and traditions on those working and learning in the institution is profound. Indeed, they create its master teacher, the institutional ethos. Because its origins are so widespread in place and time, the ethos exerts its influence ubiquitously and invisibly on the policies and actions of the school.

I once was approached by a high administrative officer of a medical school, a physician, to discuss where in the curriculum he might do some teaching, because he really missed it. At the time I too believed in the basic educational dichotomy between administration and faculty, and did my best to help him choose a good class in which to participate. Given that same request from him now, my response would be different. I would suggest that the opportunity to teach is not restricted to the instruction of students in a classroom or clinic. I would point out to the administrator that when he creates and oversees budgets, policies, and educational initiatives, and influences by these actions the communities within and outside of the school, he teaches powerful lessons. I would say that his role as an institutional leader provides an unparalleled visibility and platform from which to instruct the organization's community about matters such as the stewardship of resources, the humane use of authority, the role of values in making judgments, the exercise of patience and courage under duress, how to admit mistakes, how to forgive them, the application of knowledge in taking action, the balance of personal and professional commitments, and so forth.

It is critical that institutional leaders be self-conscious in their roles as teachers and aware of the linkage between policy making and education. It also is important for them to include the institution's constituents in the crafting of policies, as an affirmation of its commitment to open discussion. Institutions show their respect for the dignity and experience of their constituents by giving those affected by choices a voice in helping to shape and decide them. I don't mean by this always seeking to fill auditoriums to decide issues, although this may sometimes be advisable. I mean doing things such as using focus groups of institutional personnel to test ideas; inserting policy questions where appropriate in student forums; using weekly newsletters to alert the community to problems and to ask for suggestions; periodically revising the institutional mission statement in consonance with changing constituent views of school goals; encouraging administrative and departmental units to have periodic meetings about the character of life within them and the school; focusing on hierarchical behavior in the institution to determine how authority is used in academic and staff relationships; asking how the school interacts with its neighborhood and whether this relationship needs change; and so forth.

In constructing its policies, the medical school has an opportunity to fashion its actions on the same foundation that it endeavors to teach in class to its students - the foundation of ethics. The standards that bind physicians together as a profession, that distinguish medicine from business, and that enable individuals when sick to place themselves in a physician's hands constitute the ethics of medicine. If students are urged to use these ethical standards as beacons of right action, shouldn't the institution that educates them do the same?

In illustration of this, let us examine one of the major institutional challenges facing American medical schools - how to survive financially without undermining their educational and service missions. Buffeted by the loss of practice income in the 1990s under the ethos of competition for patients with managed care organizations, and the growing unwillingness of private and governmental payers to factor education time into fee schedules, medical schools have responded with policies under which clinical faculty devote ever increasing amounts of time to reimbursable patient care to make up the revenue shortfall. This in turn has reduced the time they can give to teaching, research, and institutional and community service. Concurrently, many schools have expanded the bureaucracy concerned with practice faster than other aspects of their mission, thereby changing its direction and character.

(Continues...)

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Table of Contents

Contents Preface Jordan J. Cohen....................ix
Introduction Delese Wear....................xi
PART ONE Understanding the Experience of Medical Education The Moral Order of the Medical School Stanley Joel Reiser....................3
In Search of a Lost Cord: Professionalism and Medical Education's Hidden Curriculum Frederic W. Hafferty....................11
Professional Role in Health Care Institutions: Toward an Ethics of Authenticity Richard Martinez....................35
Professional Ethics and Social Activism: Where Have We Been? Where Are We Going? Jack Coulehan and Peter C. Williams....................49
PART TWO Shaping the Experience of Medical Education Student Advocacy for a Culture of Professionalism at the University of Kentucky College of Medicine Sheila Woods, Sue Fosson, and Lois Margaret Nora....................73
Moral Growth, Spirituality, and Activism: The Humanities in Medical Education Judith Andre, Jake Foglio, and Howard Brody....................81
Reflections on Experiences with Socially Active Students Mary Anne C. Johnston....................95
The Mentor-Mentee Relationship in Medical Education: A New Analysis Tana A. Grady-Weliky, Cynthia N. Kettyle, and Edward M. Hundert....................105
From Identity Purgatory to Professionalism: Considerations along the Medical Education Continuum Norma E. Wagoner....................120
Experiencing Community Medicine during Residency: The La Mesa Housecleaning Cooperative Frederick A. Miller and William D. Mellon with Howard Waitzkin....................134
Community-Oriented Medical Education: The Toronto Experience DonaldWasylenki, Niall Byrne, and Barbara McRobb....................150
The Case for Keeping Community Service Voluntary: Narratives from the Rush Community Service Initiatives Program Edward J. Eckenfels....................165
Bridging the Gaps: Community Health Internship Program-A Case Study in the Professional Development of Medical Students Lucy Wolf Tuton, Claudia H. Siegel, and Timothy B. Campbell....................174
Afterword Janet Bickel....................184
References....................193
Contributors....................209
Index....................213

Editorial Reviews

Unfortunately, too much publicity and discussion continue within and beyond medical academia, primarily about Medical College Admission Test scores, passing board examinations, lack of reimbursement for patient care costs, the rise in cost of medications, malpractice suits, and increasing clinical—ie, fiscal—obligations for physician faculty, curtailing time with students and residents for demonstrating authentic professionalism....This thought-provoking, inspiring, and challenging book is a "must read" for all medical school administrators, faculty, staff, residents, students, and those considering a career as a physician or advising others about such a choice.

Journal of the American Medical Association