The American Journal of Bioethics 4.2 (2004) 40-43
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The Role of Empirical Research in Defining, Promoting, and Evaluating Professionalism in Context
Delese Wear and Mark Kuczewski (2004) have done medical educators, students, and patients a great service by pointing out that the discourse on professionalism has been too abstract and has placed the burden of being evaluated for professionalism almost exclusively on the shoulders of students. Indeed, proceeding to evaluate students' behavior without understanding what professionalism means in day-to-day clinical practice and without providing an environment that clearly promotes and rewards these behaviors risks harming students and further entrenching prevailing power structures and deficient modes of instruction. Wear and Kuczewski, however, have hinted at several points that, in the spirit of promoting an inquiry into what professionalism means in practice and of providing a roadmap for educators, we'd like to clarify and elaborate. We also will expand on how Wear and Kuczewski's propositions might be informed by existing empirical research, and we propose additional types of empirical research that should be conducted to aid in the reform of current practices.
Wear and Kuczewski do not clearly draw distinctions among:
- using normative theories of professionalism in understanding what professionalism should be;
- specifying in detail what the abstract terms we are using to characterize professionalism mean in day-to-day-practice; and
- identifying how the training environment fosters and hinders professional character and behavior.
As a result, they undervalue the contribution that theory should make to defining professionalism [as McCullough (2004) and Jecker (2004) point out], seem unfairly and inappropriately to privilege students in the task of defining professionalism, and give short shrift to existing empirical research on the training environment. And, oddly, they do not stress that senior physicians and medical school faculty must be held to the same standards for professional behavior as students. Students, physicians, faculty, and, we'd like to add, empirical researchers, have different roles to [End Page 40] play in defining what professionalism is in practice, assessing the training environment, and creating environments that promote professionalism.
Defining What Professionalism Is in Practice
Wear and Kuczewski correctly cast students as experts on the challenges they face in their training environment. Most students, however, are not likely to be experts on reflecting about how those challenges relate to their developing professional identity or on defining what their professional identity should be. In claiming that students "try to enhance their own professionalism," the authors are attributing an action to students that students are likely not aware of or don't experience in this way. So, while students' views of what the abstractions mean in day-to-day practice are of great value and must be part of defining what professionalism means in practice, students should not be the only source, or even the primary source, of what professionalism should mean in practice. Such definitions should be the outcome of student views in dialogue with the views of educators, with professionalism theory, and with what empirical research has to tell us about the training environment.
Assessing the Training Environment
Wear and Kuczewski discuss the importance of the training environment for promoting students' professionalism, but they focus on student abuse. Other empirically identified factors that create an inhospitable environment for the cultivation of professional norms include: stress in medical school caused by information overload, the impersonal nature of much of the first two years of coursework, evaluation pressure, lack of significant interaction with faculty or with patients in the preclinical years, limits on student-patient relationships caused by shorter inpatient stays and a dearth of opportunities to learn in the outpatient setting, and lack of institutional recognition of the importance of student-faculty mentorship(Conrad 1988; Lloyd and Gateley 1990;Morton et al. 1996). Several authors focus on the lack of opportunity for reflection that this training environment provides for students...