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.
Great this issue is being raised. But I don’t believe professionalism can be taught as a subject…but must be lived and practiced by those who teach.
Sadly, those who teach, create standards and regulations are the least free to make uncompromised choices. They practice in a field charged with seduction, censure and conformity. Who among them can afford unpopular “right” decisions without risking their position? Doesn’t happen at Google and certainly doesn’t happen in Academia.
We know that already from the toppled statues at “elite” ivy league schools. Our once “ivory towers” have pushed aside learning for the Enforcement of Niceness, a new kind of spiritual fascism. Campuses have been repurposed to be cost-ineffective open hospitals. Here, young adults can wander without worries. They no longer wrestle with grasping reality. They have been taught reality is what they feel and revolves around each of them.
We all have a lot of back pedaling to do…and we won’t have the freedom to do that without first changing up the rules and those who make them.
Peggy Finston MD
http://www.Acu-Psychiatry.com
Peggy Finston MD
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Professionals profess. PROfession means to speak on a subject BEFORE opposition is given. CONfession means to agree with (after or simultaneously to) an accusation.
This is the same difference as that between CONtrition and Attrition. The former being sorrow for violating a principle (for wrongdoing) while the latter is sorrow for being caught in wrongdoing.
Thus, a professor is is one who places principle above self, rather than the opposite, the confessor, placing self above principle (not an entirely accurate etymology, but appropriate for this point)
This a matter of metaphysics, that which is beyond the reach of physics (the measurable). Measuring (i.e., defining,) professionalism is the same as measuring integrity, which is akin to measuring the “rightness” of a cloud or a sunset. To quote a well known adage, “How do you solve a problem like Maria?” Answer: you dont’t, because Maria isn’t a problem outside the bounds of pre-set guidelines.
The “problem” like Maria isn’t about the object (Maria’s behavior); it is about the subject, the observer.
Disclaimer: subjective perception is NOT intrinsically morally “right” or “wrong”, but it is intrinsically “subjective “, i. e. , personal. Thus, the subjective observer may be sincere, consistent and wrong.
In response to Joshua Briscoe:
My “list” was simply to provide a few examples that illustrate not only the breadth of behaviors that professionalism includes, but also that it can be taught with relative simplicity.
With regard to your comment that my suggestions are “the lowest common denominator”, I hope you simply misinterpreted my reply rather than were being insulting.
I provided a range of examples that professionalism entails, from physical presentation to skillful actions, again, to say that there is a wide range of areas in which we can focus professionalism teaching in medical school and beyond.
When you ask: “Where does it factor in when we discuss whether we wear white coats or not, ties or not?” you miss the simple point that being well-presented can be taught. There are many forms of being presentable in the workplace and there are a range of acceptable standards. To get lost in the weeds and imply that I suggest ONE way of being physically presented to exude professionalism misses the point.
Further, your question: “Where does professionalism factor into whether we advocate for physician-assisted suicide?” confuses ethics with professionalism. Professionalism has nothing to do with this topic. I suggest cautious use of these terms as it contributes to an obscure discussion on a topic that does not need to be “elusive” as you suggest.
Conversely, professionalism IS a factor in HOW we deliver news to patients and families. This area we can absolutely teach to students.
Finally, nothing about what I said is intertwined with my personal morals. I hoped to avoid this potential confusion by providing a definition of professionalism and how it is cultural, community based and should be defined by all parties involved, including physicians, patients and local general public.
Despite the difficulties of teaching professionalism, there is some low-hanging fruit to quick-start this effort. My longstanding offense with the medical doctors is being addressed by my first name when I am expected to address them by their title. It’s rude and condescending. I do believe that it’s inadvertent in the vast majority of cases. Decades ago in my internship I was instructed by my clinic supervisor [who was, ironically, quite egotistical] not to do this. There is more low-hanging fruit to start with that can have collective impact: If medical students are, indeed, intelligent, they might just grasp the concept of professionalism and behave accordingly.
Spot on Susan. I believe in respecting the pt. If I expect to be be called “doctor” by a pt then is it that unreasonable for me to respect them by using a similar honorific?
I can’t tell you the number of residents I have told to give respect, especially to geriatric pts. It goes a long way.
I am sorry to say that this article reflects the types of ongoing discussion on professionalism and why it has become difficult to teach.
People speak of it in nebulous terms (calling it “enduring and sacred, bound in habits….”), confuse it with morals and ethics (which it is not) and don’t develop a crystal-clear definition.
Thus, the medical and healthcare institutions are unable to find solutions to improving related curricula.
First, professionalism can most definitely be taught, though one could argue it is somewhat more challenging than teaching ischemic cardiac disease.
Professionalism is the set of behaviors that a community decides should be admired or respected in the related trade.
This means there will be cultural differences from city to city and institution to institution, however there will be behaviors that cross most of the ecosystems. This also means that both the general public, our patients, and physicians all contribute to the definition. These groups need to come together for creating a transparent, unequivocal definition of professionalism and the list of behaviors that should be the focus of improvement.
In the most simplest form professionalism is showing up to work on time, well groomed, and appropriately greeting patients and families. All of these items can certainly be taught.
Further, professionalism in medicine includes how we talk about our patients behind closed doors (it is currently inappropriately filled with prejudices), collegiality and cordiality, being immensely knowledgeable and capable to perform related procedures in your field. All of these items can be taught, and if not directly so, a system built around encouraging certain professional behaviors.
Dr. Taicher, your list, although commendable, reflects underlying presuppositions that are themselves “morals and ethics.” The “system built around encouraging certain professional behaviors” is the antidote to the hidden curriculum that clinician educators have been seeking after for some time. It has been elusive because culture changes slowly and has homeostatic mechanisms to preserve the status quo.
Should we submit only to a lowest common denominator of professionalism like you describe? Where does professionalism factor into whether we advocate for physician-assisted suicide? Or increased access to healthcare? Or improved mental health services? Where does it factor in when we deliver bad (or good) news to patients? Where does it factor in when we discuss whether we wear white coats or not, ties or not?
The conversation is broad and deep.