In a recent First Opinion, David Rothman spotlights the challenge of teaching professionalism in today’s medical schools. As president of the Institute on Medicine as a Profession, Rothman brings a needed attention to the necessity of professionalism education, of providing small grants for professionalism forums, and the power of faculty influence — among other practical suggestions. He argues that teaching professionalism isn’t necessarily difficult, it just requires intentionally:
“Today more than ever, we need physicians who are committed to the principles of professionalism. The principles themselves are well-established … 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.”
Plato and Aristotle struggled with this question: Can virtue be taught? We must grapple with something similar: Can professionalism be taught? If what we mean by professionalism is a list of precepts that medical students can memorize and regurgitate in a multiple-choice exam or small group setting, then yes — it isn’t difficult to teach that sort of professionalism.
But if by professionalism we mean something enduring and sacred, bound up in habits that reveal a certain way of life and practice, then the task is more complicated. Anyone can slap autonomy, beneficence, nonmaleficence, and justice on a PowerPoint slide and call it an ethical foundation. Establishing the trajectory of a lasting, ethically professional life is more difficult, but that is precisely the task before us as medical educators.
While professionalism may not be something medical students “absorb” outright, they are spongier than we might think. Philosopher Francis Schaeffer wrote that people catch their presuppositions the way a child catches measles. So it is with moral character and professional behavior. The moral environment medical students find themselves in will incubate their ethical presuppositions. Without intentionally tracking their formation, medical students will passively absorb the habits and ethics of their peers and superiors, and call those around them to participate accordingly (for good or for ill).
The strongest evidence for this may be the “hidden curriculum.” Well-known to medical educators, the hidden curriculum refers to the lessons medical students receive in the real world, in which the high ideals of humanism suggested in medical school lectures on professionalism and ethics are often subverted and replaced by the cynicism, burnout, and misanthropy that fester behind the scenes.
One medical student described the hidden curriculum to me as “when they tell us what is right but show us what is wrong.” The hidden curriculum suggests that unprofessionalism can be — and is being — absorbed, often in spite of the explicit teaching of professionalism.
In a viewpoint in Academic Medicine titled “Professionalism in Modern Medicine: Does the Emperor Have Any Clothes?” psychiatrist and theologian Dr. Warren Kinghorn and colleagues affirm that professionalism education is not only undermined by the hidden curriculum, it consistently overlooks the reality that it is the local moral community — embedded in specific moral practices, living traditions, and active relationships — that shapes a trainee’s conception of what is good and what is professional.
And yet, medical students may be disconnected from moral communities, disillusioned by moral traditions, or just have little time or direction to apprentice themselves to wise, virtuous professionals. Instead, they are left with contrived small-group discussions and online modules,, which they click through mindlessly (who can blame them) to learn the principles of professionalism without the practical wisdom and community formation necessary to make those tenets living, interesting, and active.
Just as “empathy” erodes into the vague moniker of “niceness,” professionalism risks dissolving into a series of platitudes that no medical student would likely deny but few know how to practically embody. The dilemma is one posed by Jonathan Imber, a sociologist of professionalism: “not whether the emperor has no clothes, but whether the clothes have no emperor.”
How then should professionalism be taught? Palliative physician Dr. Farr Curlin and surgeon Dr. Daniel Hall say it isn’t clear what lasting curricula for professionalism and practical wisdom would look like in today’s medical schools. (Indeed, whether something like virtue or professionalism can actually be taught in today’s spaces of higher education is doubted by some.) As the agrarian poet Wendell Berry writes, reflecting on the formation of a virtuous professional:
“What he knew — and this involved his knowledge of himself, his tradition, his community, and everybody in it — was that trust, in the circumstances then present, could beget trustworthiness. This is the kind of knowledge, obviously, that is fundamental to the possibility of community life and to certain good possibilities in the characters of people. Though I don’t believe that it can be taught and learned in a university, I think that it should be known about and respected in a university, and I don’t know where, in the sciences and the humanities as presently constituted, students would be led to suspect, much less to honor, its existence.”
When it comes to calls for professionalism education, the image here should not be the lecturer at the lectern in front of a PowerPoint but “the master harpist carefully shaping the technique and style of the aspiring beginner.” Lasting, robust professionalism cannot be imparted by list, syllogism, or any set of ethical postulations, no matter how elegantly they are transcribed or articulated. It can be done only in the candor of friendship, practical mentorship, and community, nourished by living traditions, authentic habits, and robust practices that unashamedly claim that they matter beyond personal preferences, “best answers” in question banks, small group evaluations, or even professionalism consensus statements.
Young professionals need the witnesses and relationships of the local moral community to teach them what to “profess” and how to embody such a professional life.
Like Rothman, I hope we do “adopt a more deliberate and integrated approach to teaching professionalism.” But I also hope we aren’t missing the forest for the trees. Teaching professionalism is difficult, and it will require something like capturing imaginations and sharpening iron. I suspect it will look less like a lecture and more like a friendship.
John Brewer Eberly Jr., M.D., is a recent medical school graduate and a fellow of the Theology, Medicine, and Culture Fellowship at Duke Divinity School.