The American Journal of Bioethics 4.2 (2004) 11-12
[Access article in PDF]
The Formation of Physicians
David C. Leach
Many people are unhappy with the healthcare system. Patients are concerned about their safety and whether care is appropriate; doctors are frustrated by numerous constraints put on their traditional role as they attempt to determine the best means toward the best ends for individual patients; and all are concerned about the costs of healthcare (Kohn, Korrigan, and Donaldson 2000; Committee on Quality of Health Care in America 2001). In recent years the Accreditation Council for Graduate Medical Education (ACGME), the body that sets standards for and accredits the nation's 7800 residency programs, has developed an initiative designed to improve graduate medical education by using educational outcome assessments as an accreditation tool.1 Six general competencies have been identified that frame, and to some extent define, the substance of medicine independent of specialty and independent of delivery model. The six competencies are:
- patient care;
- medical knowledge;
- practice-based learning and improvement;
- interpersonal and communication skills;
- professionalism; and
- systems-based practice.
Professionalism is one of the competencies; the community of medicine is currently in active dialogue as it attempts to discern what this word really means.
Delese Wear and Mark G. Kuczewski (2004) substantially contribute to this conversation and highlight a perspective crucial for accreditors, residents, and faculty. At the heart of their article is an insistence that attributes of both the individual and the context must be considered when evaluating professionalism. They caution against abstractions and instead frame the issue as "the norms for the relationships in which physicians engage in the care of patients" (Kuczewski 2001; Kuczewski et al. 2003), grounding us in the particulars of the doctor-patient, doctor- colleague, and profession-society relationships. This frame focuses the problem nicely, incorporates both sociological and individual perspectives, and guides us to consider both individual attributes and the context in which these relationships are conducted. Philosophy may seek wisdom, but medicine seeks practical wisdom and their definition is practical.
Wear and Kuczewski's remarks integrate the two roots of professionalism—community and character. They are Aristotelian in expressing an interdependence of community on formation of character and of character on shaping communities.
Skill acquisition in professionalism, as in other things, is developmental and proceeds through a continuum. Although insights might occur in a flash, competence in professionalism develops over time and is nurtured by reflection on experiences; it is a habit. Dreyfus (2001) has developed a model of knowledge and skill acquisition that is simple, elegant, and relevant for medicine. The named stages of novice, advanced beginner, competent, proficient, expert and, more recently, master add depth and breadth to conversations about competence and offer alternatives that reflect the developmental nature of competence. This model gets us closer to the reality of how physicians learn. Professional formation is aided by rules that must be learned (novice, advanced beginner) and these rules must be applied in increasingly complex contexts (competent, proficient, expert, and master). Residency should systematically foster development from advanced beginner to competent. Correctly conducted, it forms human beings into doctors who have acquired the habit of competence in the domain of professionalism (Leach 2002). This is an area of great interest to the ACGME, the 7800 residency programs in the United States, and the 100,000 residents whose formation is being nurtured (or not) in these programs.
In order to be competent, residents must be involved enough to be accountable. In the Dreyfus model, moving from advanced beginner to competent means less detachment and greater immersion in particular contexts; it means moving from rule-based behaviors to context-based behaviors. As residents encounter particular patients and situations and attempt to apply the correct rules, they are forced to select a perspective. Not all the details of a particular case are equally significant; some are more relevant than others. Learners select which details are relevant and in doing so select a perspective from which to view the case. Understanding the particulars of context and how they inform correct...