The American Journal of Bioethics 4.2 (2004) 45-46
[Access article in PDF]
The Professionalism Movement:
A More Optimistic View
Alan B. Jotkowitz
Delese Wear and Mark G. Kuczewski (2004) state in their thoughtful critique of the professionalism movement that the topic of learning professionalism "dominated the content of many academic medicine publications and conference agendas during the past decade." As practicing physicians and medical educators, we applaud this renewed emphasis on professionalism in academic medicine. The role of physicians as gatekeepers, the challenge of the uninsured, and the rise of the pharmaceutical industry all serve as daily challenges to the time-honored role of the physician as an altruistic, emphatic champion of the sick and threaten the integrity of the doctor-patient relationship. These rapid changes in healthcare also affect medical education, and students may too easily be influenced by the realities of the new environment. The professionalism movement was reinvigorated to counterbalance these developments, and in our minds not a moment to soon.
Wear and Kuczewski raise concerns about the professionalism discourse in terms of its overly abstract nature and the insufficient attention it pays to social factors, particularly gender. The professionalism literature is indeed heavily imbued with abstractions, but by its very nature professionalism is a little harder to define than a "flower." The necessary first step in improving professionalism both on an educational and practical level is to define the attribute, and that is precisely what has been done to date. In addition, the recently completed "Physician Charter" on medical professionalism (ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine 2002) goes well beyond merely defining the attribute to mandating specific behaviors incumbent upon physicians.
Obviously the further development and application of the principles of professionalism entail the involvement of a variety of stakeholders. We do not disagree with the necessity of discourse with students and young physicians. But we do think that no less critical, and perhaps even more so, would be discourse with the public, patients, and their families.
Student abuse and gender-specific problems obviously can impact on and ultimately affect physician behavior. But the emphasis on students' personal problems and on women's problems in particular, we believe is overemphasized. We do not understand how gender should impact in a major way on the definition and/or practice of professionalism. Professionalism should be gender-blind and the practice of it required equally by male and female physicians. The literature also suggests that female physicians are more empathic (Bylund and Makoul 2002), an essential attribute of professionalism, than male physicians. Obviously, medical schools and residency programs should be evaluated in terms of how they address deficiencies in the learning environment, but we do not think that "crying rooms" or "flex parenting" tracks are of major import in their potential impact on the pursuit of professionalism, although we certainly support them.
We certainly concur that the professionalism of students should be fostered by encouraging positive behaviors and that student abuse is an anathema to any concept of professionalism. But from an educational perspective student abuse is but a small, albeit important, part of the larger problem of the hidden curriculum in medical schools. Many attitudes and values that we spend much time emphasizing in our formal curriculum, such as empathy and altruism, are undermined in informal settings. Behaviors that we preach are sometimes not practiced in the [End Page 45] clinical settings, and sometimes the opposite behavior is glorified. Improvement and prevention of patient abuse should receive at least as much attention as student abuse. This is the essence of the hidden curriculum, and its negative role models and practitioners can be distinguished professors or student peers. For example, moral development, which one might have expected to grow in medical school, has been shown to be stunted (Patenaude, Niyonsenga, and Fafard 2003), and students' attitudes and potential behavior with regard to whistle blowing have been shown to not change during medical school (Goldie et al...