The development of professional character in medical students.

What is a professional? A professional commands a special body of knowledge and skills. A professional also is given specific rights not generally provided to the public, and has specific responsibilities or duties not generally expected of the public. What distinguishes a professional from an expert, then, is the contract negotiated between a specific group of experts and society.[1] In trade for specific rights--physicians, for example, have the right to ask private and personal questions, to prescribe narcotics, and to perform operations--professionals must accept responsibilities or duties not expected of society in general. These include confidentiality, compassion, integrity, interprofessional respect, public service, responsibility, and self-policing.[2] These are values that society expects its physicians to uphold as professionals, and values we intend to teach, promote, or at least not destroy in the course of medical education.[3] But there is good evidence that we in fact inhibit or impair the development of positive professional values in medical education. While the formal curriculum of medical school espouses professional values, the informal curriculum may teach something quite different. How Professional Values Are Taught The formal curriculum of values is taught in medical school through both texts, including the medical school's statement of goals, and experiences. The goals statement of the medical school at the University of Michigan, for example, reads: [The medical school's] goals will be attained when students have acquired ... [i]nterpersonal skills that facilitate effective and empathetic relationships with patients and effective collaborations with other health care professionals; the professional attributes of compassion, honesty and integrity; and social and professional responsibility in the context of a diverse and changing society ...[4] Formal curricular experiences include courses variably titled "Introduction to the Patient," "The Patient-Physician Relationship," or "Doctoring," in which the principles of the doctor's behavior and relationship with patients are explored.[5] Other formal curricular experiences in medical school are similarly designed to instill some of the professional characteristics expected of doctors. The Arnold P. Gold Foundation for example, has supported an exercise in North American medical schools in the last few years in which entering medical students are provided with a white coat and a lapel pin, signifying their preliminary initiation into the profession.[6] During this exercise, students are advised that the wearing of a white coat signifies the acceptance of a code of professional conduct, and that the public has very specific expectations of the wearer's behavior. Although many of these entering students will not have significant patient contact for at least two years, they are explicitly appraised of the standards to which they will be held. Although some institutions continue a few formal lectures and seminars into the third and fourth medical school years, professional values are heavily influenced by the socialization process that occurs during the clinical portion of medical education. While the values taught in the formal curriculum of the first and second years are highly consistent with the values outlined by the school and the profession, the values learned in the informal curriculum of the clinical years are highly variable.[7] Some values are enhanced, some are ignored, and some are overtly inhibited through demonstration or explanation, through parables, and through the negotiation of values conflicts. When asked how values are taught in clinical medical education, many individuals respond with "role-modeling." As Melvin Konner noted in his first-hand account of medical school: The physician's attitudes, mindset, moral stance, and the hour-by-hour decisions about how to use one's time--all these and many other matters, even including how and what and how much to feel, are observed by the student and imitated assiduously. …