The American Journal of Bioethics 4.2 (2004) 18-19
[Access article in PDF]
Returning to Professionalism:
The Re-emergence of Medicine's Art
David J. Doukas
Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.
Delese Wear and Mark Kuczewski's "The Professionalism Movement: Can We Pause?" (2004) is a helpful addition to the ongoing conversation about what it is to teach professionalism. They cite several areas of professionalism that need further work: that the concept is "too abstract;" that it requires the input of the learners; that there is poor role modeling by teachers; and that there is a need to emphasize social justice. Wear and Kuczewski's four areas of contention regarding professionalism are relevant, though not all are necessarily on the top of educators' lists of things we need to teach in medical education regarding professionalism. While one might easily agree that social justice is important to teach, such education needs to be part of a broader framework of virtues-in-practice (Pellegrino and Thomasma 1993).Teaching social agency is needed— advocacy not only for the patient in front of you but also for the 99 behind him or her. On the other hand, while transparency of medical school policies is a lofty goal, the financially bloody battles over how a dialysis unit was expanded at the expense of closing a geriatrics psychiatry unit is unlikely ever to be made part of student discourse and is even less likely to be discussed with students by the decision makers themselves.The interesting idea of "professionalism portfolios" reminds one of the folders of art children keep until their graduation from high school. Such a longitudinal gauge of one's progress might be quite meaningful and could be revisited repeatedly during one's professional development. A portfolio could reveal the evolutionary map of values that enlightens one's future professional practice.
Unfortunately, the concept of professionalism has been bandied about in whatever context the user intends. The current discussion of professionalism is like the fable of six men assessing an elephant: you believe what you perceive. Professionalism's educational re-emergence is not so much new as a return to the old. As McCullough (2004) notes, scholars of medicine, such as Gregory 200 years ago, have articulated what it means to be a professional.Ancient and recent physicians (and those in between, such as Paracelsus) knew that much of what they did was art. Up until this past century or so, the science of practice did not have firm grounding. During the last century, we so embraced the technological aspects of science that we have forgotten to teach about the art of caring for the patient. The technological imperative (and its accompanying hubris) required scientific responses with diagnostic tools (e.g., EKGs, X-rays, MRI scans, and genetic testing) and scientific interventions (e.g., CPR, long-term nutrition and hydration, and chemotherapy). Somewhere along the way, we misplaced our concern for the patients and their loved ones.
The most compelling aspect of Wear and Kuczewski's article is their positing "Let: Abuse of Students = Bad Pedagogical Practice." The work of medical education is hard, the hours are long, and not all teachers are paradigmatic role models of virtuous behavior. In the last century the emphasis in medical education has stressed accruing a scientifically-grounded medical diagnostic and therapeutic database in the preclinical years, followed by increasing levels of responsibility in hands-on practice (clinical years of the medical school, residency, and fellowship). Issues such as ethics, multicultural respect, and the humane practice of the art of medicine have been pushed aside. Only with the emergence of bioethics in the 1970s was [End Page 18] there a ramping up of medical ethics education in medical schools. These efforts were mostly didactic and small-group discussion interactions, with little attention given to the role modeling of...