The American Journal of Bioethics 4.2 (2004) 24-25
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Is Diluting Core Values a Good Idea?
Donald B. Louria
Instilling a desirable set of lifelong values, behaviors, and attitudes into medical students and residents under the rubric of professionalism can be difficult, but surely it is necessary for the proper functioning of the profession. Delese Wear and Mark G. Kuczewski (2004) argue that in the 21st century our approach to developing professionalism needs to be modified and broadened. They make several recommendations. In numbers one and two they suggest that medical students and residents need to play an increasing role, both in regard to a greater focus on gender issues, family requirements, and so on; and in developing a theory of professionalism. The concept of professionalism and its discourse might need a bit of adjusting, but I would argue that we should be very careful in profoundly expanding and altering the concepts and that there are bedrock values, attitudes, and behaviors that are virtually immutable and have been from the time of Hippocrates. In essence, the attributes of professionalism are what the aspiring doctors and residents owe the profession.
Recommendation three focuses on the abuse of medical students. Implicit in that is the assumption that "abuse" somehow interferes with the development of professionalism in these "victims." In my judgment, that focus is a mistake. Most of the "abuse" occurs in the clinical years, and the definition, according to the references cited, includes harsh or negative words deemed as unfair, unjust, humiliating, or belittling. It also includes perceived excessive workload, sleep deprivation, and perceived inappropriate evaluation. In the references cited, these were the most frequent "abuses," and all were self-reported. Some cases of "abuse" would be considered a legitimate part of the educational process. For example, in one case a student listed as abuse a comment on a missed diagnosis of ruptured aortic aneurysm (that resulted in death), to the effect that an astute medical student should have considered that diagnosis (Rosenberg and Silver 1984). That hardly seems to qualify as abuse. Since so much under the rubric of abuse is self-reported and subjective, it would seem necessary [End Page 24] to be able to clearly link the various "abuses" (some of which are certainly real abuse) to subsequent problems in developing the attributes of professionalism. Because that has not been done, the whole issue of abuse is largely irrelevant to the argument. However, the notion, submerged by the focus on abuse, that residents, attendings, and others should themselves behave with professionalism is valid and of overarching importance. The doctors and nurses who relate to and teach students should be role models, and that requires unbending professionalism. This is not routinely drilled into residents, fellows, and attendings. It should be. It should also be a mandatory component of continuing medical education for all physicians, especially those in teaching roles; and it should be an obligation of every medical school and hospital department, through grand rounds presentations, role playing, and so on. If attending physicians (part-time and full-time) act as role models in this regard and demand it of their residents and fellows, medical students will have those attributes instilled into them. That should also be true of nurses, but we have so mangled that profession that developing nurse role models for inculcating professionalism for residents and medical students might be difficult in many settings.
Wear and Kuczewski's final recommendation ties professionalism to social justice and social activism. That is an interesting concept. Surely including the avoidance of stereotyping and prejudice belong in the core components of professionalism. However, the argument becomes murky when Wear and Kuczewski link professionalism and its discourse to the analysis of distribution of power, to institutional policies, and to social activism. These are important issues, but are they part of professionalism? Does their inclusion dilute the core values in the concept of professionalism? If the definition is to be extensively expanded, where does it stop? I could argue that the discourse should then...