The American Journal of Bioethics 4.2 (2004) Web Only
[Access article in PDF]
Professionalism from the Apprentice's Perspective
Juan Carlos Batlle
At the University of Pennsylvania School of Medicine, an institution whose professionalism curriculum I would characterize as being neither particularly weak nor particularly strong, there is a longitudinal academic course spanning the first three years, a senior administrative employee dedicated to special initiatives like multiculturalism and doctoring as a humanistic endeavor, and a genuine concern over the professional development of its students. Medical students serve on almost every schoolwide committee, including a committee providing feedback on the day-to-day operation of the curriculum, a committee evaluating the overall content and direction of the curriculum, and multiple department-specific committees advising on topics ranging from faculty hiring to the structure of the student-physician interaction. If the professionalism movement hinges even partly on an open dialogue between students and faculty or on the "academic environment" of a medical school, then Penn's professionalism curriculum should rate highly according to Delese Wear and Mark G. Kuczewski (2004). But as they imply, the teaching of professionalism has been an elusive prize for educators, medical and otherwise. As a combined-degree student receiving an MD, an MBA, and a master's in Bioethics, I have experienced these attempts firsthand and can attest to the difficulties of teaching professionalism. As a medical student currently experiencing the movement toward limiting the workweek and toward broadening our educational exposure, I understand the importance of getting the professionalist focus right. However, I have doubts that either the framework for discourse or the environment in which professionalism is taught can correct the wayward course of professionalist education.
There is little dispute that professionalism should be a focus for concern in medical education. A "hidden curriculum" is often blamed for insinuating moral decrepitude among trainees despite formal efforts to educate them about professionalism (Hafferty and Franks 1994). For instance, a recent study used Kohlberg's Moral Judgment Interview to score medical students upon school entry and then three years later. The study found an average decline in moral judgment score over the three-year period and speculated about the power of the hidden curriculum as an obstacle to moral development (Patenaude, Niyonsenga, and Fafard 2003). In response to the apparent crisis of unprofessionalism, the Accreditation Council for Graduate Medical Education (2001), an accreditor of residency programs, has issued a new set of rules governing resident education that installs bioethics and professionalism as core educational objectives for American medicine. Although methods for assessing professionalism in practice are growing (Surdyk 2003) and medical schools and residency programs have begun to teach professionalism formally, there has been little effort, as far as I can tell, to use evidence to evaluate these educational approaches. Thus, while Wear and Kuczewski look to refocus the professional curriculum of our medical education system, they have neither proved the current system inadequate nor validated any potential replacement using rigorous scientific methodology. Without such a methodology, criticisms among competing visions of professionalist education will be largely moot.
Even evidence-based education, however, ignores a basic assumption Wear and Kuczewski have made—that while the current system of formal humanistic education is simplistic and inadequate, a potential approach exists that will adequately inculcate professionalism among trainees. As the authors point out, the current approach uses vague abstractions and rote recitations of cultural differences as the foundation for teaching professionalism. However, two reflections occur to me.
- Any formal theory of professionalism will eventually transform (whether in the recesses of our medical student memories or in the essays we write) into abstractions when deployed in the academic setting.
- The teaching of professionalism in a medical institution creates professionalists versed in an academic subject, not professionals practicing humanistic medicine.
In support of my first reflection is Kuczewski's own involvement in creating a professionalism curriculum at the Stritch School of Medicine, Loyola University (Kuczewski et al. 2003). He upholds as a model the "Loyola mantra" of leadership, integration, and justice—while these values are fleshed out with a few examples...