Today more than ever, we need physicians who are committed to the principles of professionalism. The principles themselves are well-established: physicians must be altruistic, always putting their patients’ interests first and above their own; they must be committed to lifelong learning; they must be responsible for the quality of care that they and their colleagues deliver; and they must advocate for the well-being not only of their own patients but also the population at large.
Yet medical educators haven’t always been methodical and diligent in teaching these tenets to the next generation of doctors. It isn’t difficult. It just requires an intentional focus on helping students build an ethical foundation that will let them balance competing needs and resolve moral dilemmas while also being good, caring, tolerant, and empathetic doctors.
Here are five key reasons why medical educators must do a better job of teaching medical professionalism:
Time of transformation. We are at a moment of extraordinary transformation in how medical practice is organized. Once upon a time, patients saw solo practitioners — visiting one-to-two-person offices in which the physicians were completely in charge of both the business side and the medical side of the practice. That period is over. Physicians now are usually salaried, and therefore subject to the incentives and disincentives offered by their employers. Professionalism helps ensure that patient interests, not employers’, predominate in clinical care.
Transparent environment. Physicians today practice under a high level of transparency. The Physician Payments Sunshine Act reveals doctors’ financial connections with pharmaceutical and device companies, while electronic health records make their clinical decisions available for the scrutiny of employers and colleagues. Professionalism will help ensure that the data will be used to improve patient outcomes.
Doctor-patient disconnect. There is a growing distance between doctors and their patients; in many cases, they have become strangers at the bedside. The rise of extraordinary specialization taking the form of hospitalists for hospitalized patients and laborists for pregnant women means that in many instances doctors cannot or will not know the patient they are caring for and the patient will not always know or have a prior relationship with the doctor at his or her bedside. Under these circumstances, maintaining trust is far more difficult than it is with an established doctor-patient relationship. Professionalism will ensure that patient interest continues to dominate the clinical encounter.
Governmental oversight. State and federal governments now intrude regularly on physician autonomy. Professionalism must be invoked when government bodies regulate what doctors can say or must say to patients. In 2011, for example, the Florida legislature passed a bill that limited what physicians could say to patients about firearm ownership, even though that kind of information is important to protecting adult and child health. Although the law was overturned in 2017, physicians must clarify why such intrusions are not in the best interests of patients or communities.
Patient advocacy. Patients have become far more involved in and savvy about their care. The physician monopoly of medical knowledge is broken. Patients can investigate conditions on their own by doing a simple Google search or going to the website of countless disease-focused organizations. Given this, physicians must recognize that theirs is not the only voice in the room. Professionalism makes clear that they must be more open to the perspectives that patients bring to the encounter.
Although these issues are making professionalism harder to maintain, it is also spurring innovative approaches that can serve as models for educational and professional institutions. In 2010, the Josiah Macy Jr. Foundation and the Institute on Medicine as a Profession, which I direct, launched a pilot program to encourage innovative methods for teaching professionalism to the next generation of physicians and establish professionalism as a standard to be instilled and cultivated through medical education.
A new report summarizes lessons learned from that effort. It offers important best practices from 19 educational institutions that have been developing new models for teaching professionalism. Here are some key takeaways to guide future work:
Put small grants to work. Providing small grants to medical schools had a catalytic influence on the institution. Involving faculty, students, residents, and staff in discussions about professionalism opened opportunities to discuss other issues, such as burnout and the physician’s role as advocate, and helped break down traditional barriers between students and faculty members. As a result, all 19 programs continued after the grant period and integrated professionalism into institutional curricula or residency programming.
Faculty development is essential. No professionalism program will succeed without serious attention to faculty development. Since the explicit teaching of professionalism is relatively new, most faculty members have had little experience with it as learners or teachers. Consequently, professionalism needs champions at the highest levels of the organization. This is important for both role-modeling professionalism at all levels and for the necessary commitment of time and resources. Deans and chiefs of service need to be included and visible to students and residents.
For example, a project at the University of Rochester Medical Center focused on enhancing faculty members’ skills and attitudes about patient-centered communication. It established a program in which surgeons are paired to give and receive feedback on improving communication skills with patients. The ultimate aim is to create a model for peer coaching that can be adopted by other specialties and departments throughout the medical center.
Aim for longitudinal integration. Professionalism needs to be integrated longitudinally and through the educational experience. The content and principles of professionalism must be continually reinforced. Advocacy and community-based programs have been effective ways to teach and model professionalism. The University of California, San Francisco-Fresno Pediatrics Residency Program is partnering with the Fresno United School District, Fresno State University, and other organizations to foster the development of lifelong advocacy skills among medical students.
Pay attention to burnout. Unprofessional behavior can be a manifestation of burnout, which both faculty members and students experience. Burnout makes it difficult to put patient’s needs first. Re-instilling professionalism with its accompanying commitment to purpose can be a strong antidote to burnout. Already overburdened faculty must not see this as an additional assignment but as an opportunity to be reinvigorated. Empathy and tolerance of ambiguity in medicine are critical tenets of professionalism, yet they are not taught or tested in medical training.
To combat burnout, Thomas Jefferson University joined forces with the Lantern Theater Company of Philadelphia to help physicians, residents, nurses, and medical students process the complexities of their daily experience into theatrical vignettes that will be performed. Participants are tested on empathy, tolerance for ambiguity, and burnout. Studies show that watching drama might increase empathy; this program is testing whether performing it might actually have a longer-lasting effect.
Today’s health care environment places multiple stressors on doctors and other health professionals who want to put their patient’s needs first. They are confronted by increasing demands on their time, energy, and abilities. Despite these hurdles — indeed, because of these hurdles — educators in the health professions must step up and adopt a more deliberate and integrated approach to teaching professionalism.
David Rothman, Ph.D., is the president of the Institute on Medicine as a Profession.