The American Journal of Bioethics 4.2 (2004) 16-17
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Pausing to Consider Recommendations for Recasting the Professionalism Movement in Academic Medicine
Delese Wear and Mark G. Kuczewski (2004) identify four shortcomings in the current medical professionalism movement in academic medicine, suggesting that it is important to pause and evaluate its discourse and approaches. While their observations are astute and the need for scrutiny of the movement is apparent, it is unclear whether each of their specific recommendations follows their observations and might therefore be premature. Regardless, as we pause to reflect on the professionalism movement and develop means of helping to achieve the inchoate yet important goals inherent to it, some additional observations might facilitate developing appropriate recommendations for professional education and training.
Wear and Kuczewski begin by describing the conceptual limitations of the discourse on professionalism and outline its marked inattention to social factors such as gender. These observations are foundational to the others that follow and tilt toward a larger and potentially intractable issue concerning not only the incomplete expression of the values of the profession but also a lack of a more comprehensive theory concerning its axiology. Such a comprehensive theory will likely need to incorporate primary values such as deliberation and discernment in addition to those found in current statements on professionalism. In addition, understanding the professionalism movement requires questioning the motivations of those advancing it (Miles 2002). Thus, while the professionalism movement is mired in abstractions, some conceptual clarity might be a prerequisite to mitigating them. However, as a response, Wear and Kuczewski recommend evaluating training programs in terms of their efforts to engage learners in modifying the educational environment. But it is unclear how this will address the issues they have described. While the attitudes and actions of students would undoubtedly illuminate the critical issues faced in training, and would seem to be a necessary component of educational reform, they would be insufficient for informing larger concerns about professionalism. For instance, here the attitudes and actions of patients, families, practicing clinicians, and policy makers would also be essential.
Second, Wear and Kuczewski note that the diversity of didactic approaches to professionalism might reflect the absence of a coherent curricular theory of professional development. They call for descriptions of these approaches, while being unconvinced that current attempts to measure professionalism would be useful in this task. While these observations have substantial weight, a more coherent approach to professional development would include ways of negotiating the demands of professionalism from other important aspects of medical practice such as cultural competency, physician-patient communication, and medical ethics. Take, for example, some of the professional responsibilities listed in the recently-issued physician charter on medical professionalism, such as commitments to honesty with patients and confidentiality (ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine 2002). While these are endorsable commitments, both in theory and application, contemporary scholarship in medical ethics makes clear that they might have cultural limitations and represent prima facie obligations because a strict adherence to them might be harmful to patients (Sugarman 2000). Therefore, although rich descriptions promise to aid in developing a coherent theory of professional development, Wear and Kuczewski's recommendation to include learners in the process is arguably necessary but insufficient to this task.
Third, Wear and Kuczewski reiterate the importance of the environment in shaping professionalism (Stephenson, Higgs, and Sugarman 2001). However, their recommendation to simply reward learners when they demonstrate leadership in improving relationships in the environment does not seem to meet the need for a wholesale revision of the environment.
Fourth, Wear and Kuczewski note that current didactic approaches to cultural competence are a poor substitute for larger concerns of social justice. They go on to argue that professionalism should be tied to social justice and follow this with a sound recommendation for a broader approach to education in this area.
In conclusion, Wear and Kuczewski make an important and timely call to pause and reflect on the professionalism movement in academic medicine. Such a...