The American Journal of Bioethics 4.2 (2004) 31-33
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Avoiding Fallacies of Misplaced Concreteness in Medical Professionalism
Joseph C. d'Oronzio
This commentary on the article "The Professionalism Movement: Can We Pause?" by Delese Wear and Mark Kuczewski (2004), draws on my singular experience of working with physicians who have had their licenses suspended for medical misconduct due to transgressions ofprofessional ethics. Since 1992 the ProBE Program (Professional-Problem-Based Ethics; see http://www.ethicsgroup.org/probe.html) has provided a complex educational intervention for over 300 healthcare professionals referred by 37 state medical-licensing boards that have placed them under discipline. At the conclusion of every one of these weekend workshops, the participants wanted to know why this kind of course was not to be found anywhere in their medical education. I have long considered that the need for remediation in professional ethics is a symptom of a failure in prevention (d'Oronzio 1996).
So, from the perspective of my experience with the ProBE Program the response to the central question, right up-front is: "Yes, we may pause. But ..."
It is with great hazard that we once more turn professionalism inward, toward back-filling abstract formulation of focus-group generalizations, to self-observation of the academic environment, and to the medical students and residents "as genuine experts in that environment." Of the four recommendations presented by Wear and Kuczewski, the first three address what the authors consider "rubber-hitting-the-road" problems with teaching professional ethics. Regarding each problem, they ask how we can make a professionalism curriculum meaningful and concrete for the student population. Working from a solid assumption that moral learning requires a grounding in moral problems, and complaining that the virtues approach of the past decade's worth of focus-group professionalism rarely ever hits the road, the authors identify the medical school itself as the context for moral leadership development. While I share the authors' dissatisfaction with the abstractions that have emerged from the "professionalism movement," their proposals sound much like a nuanced expression of the very trends that generated the problem. I would urge revising the professional ethics curriculum in such a way as to escape yet another fallacy of misplaced concreteness.
The most concrete context for the meeting of rubber and road is in the world external to the training context. The most influential informal curriculum will respond only incrementally, over time, through attrition. We would serve the present generation well by providing classic scenarios and hard cases on which to hone professionalism skills.
Let us first take some hints from the last decade or two of our experience with teaching bioethics in medical education. Teaching abstract principles and theories has never gotten much traction. With no experience on which to hang the abstraction, the medical student learns them like the names of dinosaurs. With experience, or in the context of classic cases, the abstractions grow feet and touch the ground. In the progression from medical school to residency to practice, the level of concreteness rises and is quickly followed by the learning curve. There is no more attentive student than a PGY-10 or 15 or so, with a specific patient-care decision stuck on the horns of a dilemma. The more concrete the issue or case, the greater is the opportunity for insight, understanding, and ultimately the will and confidence to act. To act: there's the rub.
Creating a model from this common experience when dealing directly with professionalism presents a particular [End Page 31] challenge. A similar set of hints can come from the ProBE Program experience. The acronym ProBE stands for Professional, Problem-Based Ethics to suggest the application of theoretical ethics to the practical, immediate, and identifiable concerns of the participants. The ProBE Program consists of an intensive weekend in which 10-14 clinicians join two faculty members to engage in an in-depth discussion of professional ethics focused on the specific cases that these participants bring to the table...