There are several traditional ways to teach about professionalism. Some training programs have didactic lectures on this issue. These typically focus on principle-based ethics and “rules” about professionalism. “Do this. Don’t do that.” Most educators and students will agree that lecturing about this topic has some (but limited) value. Applying concrete, principle-based concepts in an ambiguous, sometimes abstract world is difficult.
Another, more useful approach, is recognizing and remediating professionalism lapses in medical students, residents or other trainees, understanding that we must see such events as a developmental and educational opportunity. Students, residents, or other trainees – anyone involved in the care of patients – can come up against a situation or dilemma that taxes one’s limits, creates a scenario that exposes one’s vulnerabilities, or simply presents a circumstance in which the individual does not or cannot respond appropriately. When these situations occur, particularly in training, it becomes a “teachable moment” – deconstructing what happened, why it happened, and how to prevent it from happening in the future. Critical to this process is developing a sense of ownership of what happened and learning and growing from it – not being judged for it (unless, of course, it is so egregious as to be untenable and must result, either for legal or moral reasons, in some definitive sanction). The drawback with this teaching option is that, in the course of training as a student or resident, issues that a given trainee might benefit from learning more about may not arise, resulting in a missed opportunity to learn from and about important professionalism concepts during a time when they can be addressed or remediated.
Another is use of role models – “good” and “bad” – but this approach is inherently risky. While it is easy to applaud doctors with great skills in the patient-physician relationship and who are adept at handling ethically challenging situations, translating these skills and traits we see in such doctors to our learners is challenging. And it’s fairly common for learners to describe behaviors seen in the clinical or other learning environments that they regard as representing “unprofessional” behaviors. But calling these out, processing them and learning from them is not always practical. People in training simply are not going to directly challenge what they perceive as unprofessional behavior with those who are in the position of assessing or grading them, or those who are in authority. Having a safe space to talk about these incidents is one option for teaching, and a useful one, but once again, is limited because we generally hear about the situation or behavior from a singular perspective and do not have the benefit of hearing from the person who is identified as demonstrating the unprofessional behavior, nor from the others in the clinical or learning space – the patient, the family, other members of the health care team. It may well have been that the person who the learner felt displayed unprofessional behavior had a good reason for doing or saying what they did, and the limitations of the learning situation do not allow the issue to be put in context.
In his essay, “Written Role Models in Professionalism Education,” Jack Coulehan addresses these concerns when he writes, “the current emphasis on teaching and evaluating professionalism in clinical education risks failure because of the large gap between explicit professional ideals and today’s culture of medical education. For professionalism curricula to be successful, they must be narrative-based, rather than rule-based.” For Coulehan, and for many of the educators whose pedagogical pieces appear in this volume, an exploration of narrative, especially in literature, offers better preparation for the demands of maintaining standards of professionalism than approaches that rely solely on rules and checklists. Checklists certainly have a place in medicine. Atul Gwande’s The Checklist Manifesto: How to Get Things Right provides a persuasive model for using them effectively in the practical applications of medical science in order to ensure patient safety. But the abstract concepts most often associated with professionalism – altruism, duty, truthfulness, and empathy, to name a few – do not lend themselves to single, observable actions to be checked off as achieved. Rather, these concepts speak to ways of being – of professing – in the practice of medicine, especially when faced with situations rife with ambiguity. For example, educators have noted an association between an intolerance of ambiguity and declines in medical students’ attitudes toward underserved, geriatric, alcoholic, and chronic pain patients. Such intolerance for ambiguity challenges professionalism at its core. Providing students opportunities to engage with ambiguity in literary representations during their education prepares them for its appearance in clinical and other health care settings.
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