Reaffirming Professionalism through the Education Community

Professionalism in medicine is often examined by considering the effect of the corporatization of medicine, the regulation of medical care, and financial conflicts of interest. Attention should also be focused on the clinical training environment because the rules of professional conduct are learned primarily during medical school and residency. This article considers the importance of an education community in fostering medical professionalism among physicians-in-training and faculty. An education community is one in which the assimilation of knowledge, skills, and values and the development of individuals personally and professionally are priorities. In medicine, this must be done with the delivery of patient care in a context where many competing demands work for and against the existence of an education community. This paper argues that reform of residency training, mentoring, a curriculum on professionalism, and the evaluation of professional conduct are essential to building an education community that enhances medical professionalism. Defining Professionalism Political, academic, and business leaders have recognized the importance of professionalism and described its characteristics. Justice Louis Brandeis [1] believed a profession had three features: training that was intellectual and involved knowledge, as distinguished from skill; work that was pursued primarily for others and not for oneself; and success that was measured by more than the amount of financial return. Other writers [2-4] have emphasized the importance of self-regulation and autonomy in clinical decision making as hallmarks of the medical profession. Some have noted the existence of a code of ethics that sets forth a standard of conduct [5, 6]. This paper considers medical professionalism and its inherent dependency on a formative community. As a working definition, medical professionalism is a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one's own [7, 8]. Honesty and integrity are values essential to medical professionalism. The professional physician has an attitude of humility and accountability to patients, colleagues, and society. Professional behaviors include a nonjudgmental and respectful approach to patients, the pursuit of specialized knowledge and skills with a commitment to excellence and life-long competency, and a collegial and cooperative approach to working with members of a health care team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of physicians to fulfill the goals set forth for the profession by the public. In exchange for putting the interests of the patient and public first, physicians are accorded trust, respect, and the confidentiality of patients. The Education Community Although many factors threaten professionalism in medicine today, perhaps most destructive is the gradual disintegration of the education community, which hinders the transmission of values and behaviors. Physician socialization requires the assimilation of values into a personal framework. Similarly, professional conduct is shaped through interactionsor the lack thereofwith faculty, peers, and patients [9-11]. Because the learning of values and behaviors best occurs in a community with explicit expectations, medical professional education requires role models. The traditional model of medical education implemented by Osler and Halsted [12] emphasizes active learning by students working in the clinics and on the wards under the close supervision of full-time faculty. Embedded in that tradition is a community of physicians who uphold similar values and behaviors. The presence of an education community in medicine is precarious, yet its existence is essential to the profession. John Gardner, former Secretary of the Department of Health, Education, and Welfare, recently described the future of a community: If the community is very luckyand few will be in the years aheadits shared values will be embedded in tradition and history and memory. But most future communities will have to build and continuously repair the framework of shared values. Their norms will have to be explicitly taught. Values that are never expressed are apt to be taken for granted and not adequately conveyed to young people and newcomers. Individuals have a role in the continuous rebuilding of the value framework, and the best thing that they can do is to exemplify them [13]. The loss of an education community in medicine and the threat to the assimilation of professional values, attitudes, and behaviors have been accelerated by the specialization of medicine, the service demands of residency caused by the economics of health care, and the faculty reward system. First, specialization has contributed to a diminishing sense of a shared value system and a weakening of the relationships among the faculty and housestaff and medical students. Over the past 30 years, the size of the clinical academic faculty increased more than 600%, in part to expand the delivery of specialized medical care [14, 15]. Feelings of collegiality and commonality among a core teaching faculty within a small department have been replaced by closer affiliations to and identification with the goals and values of a specialty division, a research team, or a clinical practice group. Specialization also has fostered self-interest and, at times, intense competition among physicians for patients, institutional resources, and control over diagnostic and therapeutic technology [16]. Furthermore, with the expansion of fellowship training, the specialty-oriented faculty in academic medical centers shifted the focus of teaching to fellows. In 1990, in internal medicine alone, more than 8000 fellows were engaged in subspecialty training [17]. The apprentice relationship that united the senior clinician and house officer now exists between the attending faculty and fellows. The layering of fellows between residents and faculty jeopardizes mentoring of residents and medical students, which is critical to fostering professionalism and sustaining an education community. Second, the faculty reward system that favors publication and presentation rather than teaching also has undermined the education community [18, 19]. Travel by airplane has facilitated the process, as has the continuous growth of medical journals. Before air travel and national funding of basic science research, faculty rarely left an institution. They wrote papers on the train and only occasionally submitted a grant application. Otherwise, they spent most of their time teaching residents and medical students, caring for patients, and leisurely doing research. Whereas residents face increased pressure to admit more patients, the faculty face increased pressure to do research and publish, to participate in national medical organizations and research conferences, and to accept visiting professorships. Lost from the hospital wards is the constant presence of the master clinician-teacher, a person essential to maintaining an education community [20]. Third, the service demands of residency, driven by the economics of health care and combined with the loss of senior clinician role models, have contributed to a lower standard of professional conduct on the clinical wards [9, 20-23]. Previously, the attending physician was both a master of the art of medicine and its knowledge base. Residents worked hard, yet the attending physician expected them to serve as exemplary role models to medical students. Today, the attending physician does not have time to conduct a thorough history and physical examination, including a social history, at the bedside. Similarly, residents spend between 17 and 31 minutes evaluating a new patient when on call at night and 25 minutes during the day [24-26]. Worse yet, physicians-in-training now often encounter a patient for the first time on the operating table [27]. That more acutely ill patients are admitted to and discharged from the clinical wards more quickly (sicker and quicker) means that residents experience the anxiety with less gratitude and positive reinforcement for their professional service [28-30]. In the context of lightning rounds and the demands of a busy clinical team, a substantial number of medical students reveal that they have documented in charts physical examinations of patients that were not done (unpublished data). Nearly all medical students report hearing residents and faculty refer to patients in derogatory terms, and usually think such terms are inappropriate ([31]; unpublished data). Confidentiality, and at times the desires of patients, go unheeded. When queried, residents reported that after they had made a mistake, only 24% notified the family, and only 54% told a supervising physician [32]. Physicians-in-training notice the professional and unprofessional conduct of more senior clinicians. This is how they learn the behaviorsgood and badof doctoring. Unlike the harried resident or burdened faculty, the master clinician regarded teaching and patient care as a calling. The relation between the loss of community and the deprofessionalism of medicine is best understood when considering the difference between a calling and a career. When one enters a profession as a calling, one assumes a definite function in a community and operates within the civic and civil rules of the community [2, 33, 34]. When a profession becomes a career, the orientation is to impersonal standards of excellence, operating in the context of a national occupational system. To follow a profession has come to mean to move up and away. Consequently, the goal is no longer participation in a local community but rather the attainment of success, and success (depends) for its very persuasive power on its indefiniteness, its open endedness, the fact that whatever success one had obtained, one could always obtain mo