The American Journal of Bioethics 4.2 (2004) 49-51
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Pausing for Professionalism
The term professionalism education encompasses current efforts to inculcate medical students and physicians with the humanistic values and skills of delivering good medical care. Ethics education was professionalism's immediate predecessor as the umbrella label for these attempts. As the professionalism movement in medical education and training gains more momentum, there is a danger, noted by Delese Wear and Mark G. Kuczewski (2004), that "we educators will simply rename what has been called 'medical ethics' as 'professionalism' in the curriculum and consider ourselves done." To avoid this convenient trap, we believe that the professionalism education movement should heed Wear and Kuczewski's call to "pause" and that the hiatus should be used to reflect upon the history of the ethics education movement and the lessons it holds for us before forging too far ahead with professionalism education. Failing this, we risk making superficial changes to ethics education or repeating some of its mistakes. Either way, we would deny ourselves an important opportunity for substantive improvement in the professional education and training of medical students and physicians.
The seminal events that catalyzed the field of bioethics, including the Nuremberg Trials and revelations of the Tuskegee study, embodied one of its central concerns—that patients and the public could no longer blindly trust physicians to be unwavering advocates for their health and welfare. Recognizing the importance of genuine trust in the patient-physician relationship, medical ethicists brought their critiques, and the positive lessons borne of those critiques, into the mainstream of medical education. Today, nearly all medical schools have incorporated formal ethics courses into their curricula (Kao et al. 2003). In addition, scholars who have not been traditional faculty in undergraduate and graduate medical education—including philosophers, theologians, and lawyers—now routinely teach and interact with medical students and resident physicians. One of bioethics' central critiques of medicine has been that ethics cannot be defined solely from within the profession. Ethics educators' presence in medicine is an enactment of this critique, while their curricular contribution reinforces the importance of ethical practice and conduct by physicians.
In light of these successes, why has the ethics education movement been followed by such vociferous calls for professionalism education in medicine? In an educational environment in which many subjects compete for finite curricular time, many medical students (perhaps reflecting the attitudes of most clinical faculty) do not take ethics courses as seriously as other subject matters in medicine, considering them a hassle to be tolerated rather than an integral part of their professional training as physicians. Some faculty, believing that students develop the relevant attitudes and behaviors long before they arrive at medical school, doubt that ethics can be taught effectively at that stage. Therefore, the professionalism movement might be employed by some as a way of "advertising" humanistic training to skeptical students and faculty.
However, if better marketing is the lesson that we have learned from the ethics education movement, then we have won a skirmish but lost the war. To avoid the potential marginalization of professionalism education, we need to:
- create a formal curriculum in professionalism that grows with the medical student and evolves to be relevant and valuable for physicians across different specialties in medicine;
- design faculty development programs that will provide clinical faculty with the knowledge and skills to reinforce professional behavior among medical students and resident physicians; and
- give genuine priority to teaching as a core mission of medical schools and teaching hospitals.
While we agree with Wear and Kuczewski that medical students and resident physicians should be enlisted as catalysts for constructive change in advancing professionalism education, our recommendations place a greater emphasis and thus greater responsibility on the teacher than on the student. Given the institutional hierarchy and power dynamics in medical schools and teaching hospitals, it is more imperative that we address the skeptics and others who have the authority and resources necessary to make significant improvements in medical education and training.