Instilling professionalism in medical education.

Abstract

PROFESSIONS HAVE LONG BEEN RECOGNIZED TO CONsist of 3 essential characteristics: expert knowledge (as distinguished from a practical skill), selfregulation, and a fiduciary responsibility to place the needs of the client ahead of the self-interest of the practitioner. In recent years there has been renewed recognition among medical leaders of the particular importance of the third, or altruistic, characteristic in medical professionalism. For instance, in 1994 the American Board of Internal Medicine defined the “core of professionalism” as “constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.” In recent years, market forces have posed an unprecedented threat to medical professionalism—particularly the physician’s obligation to serve the needs of patients. For all its defects, the fee-for-service system that long dominated medicine had one great advantage: it allowed physicians easily to do what was necessary for patients. In contrast, today’s managed care environment has undermined physicians’ ability to provide patients with needed care. Many managed care organizations, whether seeking to control costs or maximize profits, have created strong financial incentives for physicians to restrict care. Some managed care organizations have even urged that physicians be taught to act in part as advocates of the insurance payer rather than the patients for whom they care. This has caused some critics to raise the specter of physicians becoming “double agents” who would purportedly serve the patient but in fact limit care for the financial benefit of the employing organization. In this context, the article by Swick and colleagues in this issue of THE JOURNAL is timely and encouraging. Of the 116 US medical schools that responded to their survey, 104 reported that they offer some type of formal instruction related to professionalism. The nature of this instruction varied widely, from a single “white coat” ceremony for matriculating students to a component of 1 or multiple courses. Most of the instruction occurs during the first 2 years of medical school. The authors emphasize that current strategies to teach professionalism need to be enhanced, as do methods for assessing educational outcomes. However, the study does document that at this critical time in American medicine, most medical schools acknowledge the need to address professionalism as an essential element of the education of their students. Are formal courses sufficient to instill a sense of professionalism among medical students? In another article in this issue of THE JOURNAL, Epstein argues that they are not. Epstein’s article invokes concepts from cognitive science, philosophy, and adult learning theory to describe a state of awareness he calls “mindfulness.” In Epstein’s view, the “mindful” physician possesses the mental qualities necessary for both good clinical decision making and proper professional behavior. What is especially notable is the author’s contention that the cultivation of mindfulness requires mentoring and guidance, not formal course work. According to Epstein, “[E]ach of us can identify practitioners who embody these attributes, learn from them, and identify unique ways of being self-aware. Educators can take on the task of helping trainees become more mindful by explicitly modeling their means for cultivating awareness.” Formal studies assessing the relative influence of didactic teaching and role-modeling on the development of professional values have not been conducted. However, there is reason to believe that both approaches are important, just as environment and heredity both influence the phenotype of living organisms. A number of concepts from history, the social sciences, and the humanities are central to understanding and internalizing professionalism. However, empirical evidence that formal instruction alone enhances professionalism is lacking. For more than 30 years, public charges that physicians are impersonal, self-serving, greedy, and occasionally dishonest have been increasing—despite the expanded teaching of the medical humanities and ethics at medical schools during this period. (Similarly, there is no evidence that the introduction of ethics courses in business schools in the 1980s and 1990s has produced more ethical behavior among business executives.) Sociologists have criticized medical educators—and educators in general—for their commonly held belief that formal course work can serve as “intellectual magic bullets” to shape human attitudes and behavior. Such crit-