The American Journal of Bioethics 4.2 (2004) Web Only
[Access article in PDF]
Creating a Complete Picture of Educating for Professionalism
Kristen E. Wessel
Positive and negative space are both valued and critiqued in the visual arts; they are interdependent, unable to be constructed without the other. Medical education must explore the symbiotic spaces as well, what is learned and what is taught, where the hidden and prescribed curricula meet. Delese Wear and Mark G. Kuczewski (2004) posit that medical educators must pause and reflect on discourse around professionalism. The authors suggest that the discourse lacks the voice of the learners and faculty and that preceptors must be leaders in not just the teaching but also the learning of professionalism. I agree. We have some practical barriers to achieving these goals: a lack of information regarding the learning, not the teaching, of attributes related to professionalism; a lack of reflection and discussion; and a lack of time to engage in these essential components of learning affective attributes.
Today, more and more medical education occurs in the community, within the clinics and operating rooms. Role models or preceptors are used to teach professionalism—attributes not only of ethics knowledge and application but of compassion, integrity, and altruism. Yet we know little about what happens when the learners are sent to the clinical setting. Few studies explore the experiences of the clinical setting, and an even smaller number of studies exist that fully explore what students learn in clinical settings. Until we have some level of transparency between clinical teaching and learning and the experience itself, medical education will be at the mercy of happenstance as the driving force for learning in the clinical setting.
In one of the few studies addressing learning in the clinical setting, Stern suggests that attributes related to professionalism are "learned" outside prescribed educational settings. Another suggests that the teaching inside the prescribed educational setting can include abuse, humili-ation, and neglect of the learner (Stern 1996; Branch 2000). How is the learning that occurs in clinics, call rooms, and so on, integrated into the trainee's learning and practice? How does teaching with abuse, neglect, and humiliation affect what is learned about medicine and professionalism? What do we know about how the experiences are translated to learning? I suggest we, as medical educators, know little. Compassion, ethics, integrity, and similar attributes are, as Wear and Kuczewski point out, abstract concepts that do not lend themselves to the quantitative, hypothesis-driven research funded by most medical-research entities. The push for outcomes sooner rather than later inhibits the development of the complex and diverse discussion required to discover the differences and the relationship between learning and teaching in the clinical setting. This lack of research and the push for immediate outcomes constrains the ability to understand learning in medicine.
Medical education in clinical settings is fraught with constraints. The most common are lack of time and case overloads. Lack of time and the push to keep production up often result in less-than-adequate feedback and few opportunities for discussion and reflection (Wessel 2003). A Dartmouth study demonstrates this lack of supervision and feedback, finding that most students in a third-year clerkship reported no supervision or teaching from preceptors (Carney et al. 2000). While medical students cited their clinical experiences with preceptors as a highlight of their medical school experience, the clinical experiences are often variable, changing from one preceptor to another, offering contrasting levels of experience for the students (Regnier, Welsh, and Quarton 1994). The result is haphazard and fluctuating levels of learning for students in the same program. The lack of observation (supervision), discussion, or feedback, as well as little or no opportunity for trainees to present or share, is often the result of the busy, time-and-cost-driven atmosphere of the clinical setting. Yet modeling, communication, practice, and discussion are critical to learning the attributes of professionalism.
Noddings (1984), a moral education specialist, suggests communication including modeling, discussion, practice, and confirmation are essential to the development and support...