Professionalism and the Medical Student.
One morning on your medicine clerkship, you are rounding with your attending and resident on Mr. Jones, a 65 year-old man with a recent massive upper GI bleed. Having checked his labs this morning, you know that his hemoglobin and hematocrit dropped significantly overnight, but your resident was unable to check the labs. When asked by the attending about these values, the resident replies that they were unavailable. What do you do? On the one hand, you possess important information that directly impacts on the care of your patient, but you do not want to risk "showing up" your resident on rounds-a situation which may lead to negative feedback on your evaluation.
In pondering this situation, it is important to analyze not only what you would do, but also what values guide your decision. At the heart of this dilemma lies the essence of medical professionalism. There are six fundamental elements to medical professionalism: altruism, accountability, excellence, duty, honor and integrity, and respect. As medical students, we occupy a unique position in the practice of medicine-neither part of the general population nor practicing physicians. As our four years progress, we undergo a tremendous emotional and social transformation as we adapt to our new role in society. Likewise, we experience unique challenges to maintaining these elements of professionalism by virtue of our roles in the classroom, clinic, and wards.
Among medical students, common attitudes towards medical professionalism and teaching professionalism in medical school can be heard in the following comments: "Why do we need to spend time discussing this? It's something that you either know or don't by the time you start medical school." "I already know not to talk about my patients in the elevator." "With all I have to do now, I have no time to study professionalism; besides, I'll pick that up on the wards." Despite the practical reality that these comments may reflect, it is vital that medical students are educated in the tenets of medical professionalism. If we can acquire these traits and skills in our formative years, we will not only be able to apply them to our interactions with patients, but also serve as positive role models to generations of physicians in the future.
Altruism. One of the fundamental tenets of a profession includes altruism-that is, putting the best interests of the patients above those of your own. Like many abstract concepts, this is a relatively simple definition that is difficult to apply. In the case of Mr. Jones, altruism dictates that the attending know about his lab values so that the appropriate treatment can be instituted as soon as possible. Maintaining silence over concerns of "showing up" the resident and thus earning a negative evaluation would be placing self-interest over that of the patient. Obviously, this situation is not as cut and dried as that, and it is possible to act altruistically without offending the resident. The art of applying medical professionalism concepts to real-life scenarios is a difficult one that requires practice to acquire.
Accountability. This element embraces the concept of personal responsibility-both accepting it and following through in actions. As medical students, it is tempting to ignore this concept since we have no ultimate responsibilities in patient care at this point-a resident or attending is overseeing our work. However, in a few short years, that will no longer be the case and developing accountability before that time comes is essential. So how are medical students accountable to patients? As the person with the most time on the team, medical students spend significant amounts of time with the patients and learn information that the team does not. Sharing this vital information is a responsibility of the student. In addition, admitting to mistakes when they are made, although an uncomfortable experience, further develops the element of accountability.
Excellence. Inherent in the concept of excellence are the expectation of exceeding the ordinary and making a commitment to lifelong learning. As medical students, we often fall into the mode of "what do I need to know to pass the test?" While this attitude may result in high test scores, ultimately patient care is not a multiple-choice exam. Especially in the third and fourth years, when education becomes centered around real patients, a shift occurs as students read about their patients, search the medical literature with specific questions, and ask advice of more experienced physicians and colleagues. Continually striving to do one's best in every aspect of patient care embodies the element of excellence that is fundamental to medical professionalism.
Duty. The concept of duty entails the acceptance of a commitment to service. Being a physician is more than a nine-to-five job and certain sacrifices in time and energy are required. For medical students this shift in focus can be straining. Working long hours, striving to learn while tired after many hours on the job, and accepting the constraints of being "on call" are taxing on both our emotional and physical energy.
Honor and integrity. Both of these abstract concepts involve being fair, truthful, keeping one's word, and consistently living up to personal and professional values. Once again, these ideas are easily expressed in the abstract, but can be difficult to apply in specific situations. How do you react when your resident takes out his or her frustrations with the caseload on you? What do you say to the patient who tells you something in confidence that the whole team needs to know without violating the patient's trust? How do you broach the subject of one colleague badmouthing another? It is important that students find mentors who model both honor and integrity to emulate as they navigate this unfamiliar territory and still remain true to their values.
Respect. The basis of respect is treating others as you yourself would want to be treated-with compassion and dignity. One area where medical students can practice respect is in our interactions with one another. The competitive drive to be the best student on the service at the expense of another must be subjugated by respect for fellow and future colleagues. We can practice giving respect by keeping other students informed of important developments in the team and encouraging and supporting them as they learn with us. Respect for patients is another key element of this concept. As physicians, we will interact with patients whose beliefs and core values differ from our own. Acknowledging and accepting these differences while still providing excellent care is a challenge that must be faced and conquered. An honest evaluation of your own beliefs in relation to your interactions with patients is vital in the development and maintenance of respect for patients.
So, how do we learn medical professionalism? More importantly, can it be taught at all or does it consist of a character set that a person either has or doesn't? Without delving too deeply into this rather philosophical question, let it be said that while many of these elements seem to be inherently more developed in certain individuals, all of these elements can be ultimately taught and honed. In fact, the majority of medical schools have some form whereby they teach medical ethics or professionalism. Although this is accomplished at various levels, ranging from one ceremony to multilevel courses, the teaching of medical ethics often takes two forms: didactic teaching in lectures and role-modeling from clinicians who practice professional behavior. Both forms must be present in order for a student to develop medical professionalism.
How does your medical school teach professionalism? Whether it is through formal training or informal role-modeling, we can still work at the individual level to develop professionally. Learning the elements of professionalism and noting when they arise in everyday situations will help raise our awareness of this vital topic. Discussing these concepts with fellow classmates, residents, and attendings not only furthers our learning, but gives us familiarity with these difficult concepts so that when situations arise, we are more equipped to deal with them. As with anything, practice makes perfect, or at least will make circumstances easier to manage. Medical students are given the privilege of taking care of people when they are most vulnerable. Upholding the elements of altruism, accountability, excellence, duty, honor and integrity, and respect is our sacred trust.
Council of Student Members Representative, Midwest Region
Medical College of Wisconsin, 2006
1. Siegler, M. Training doctors for medical professionalism. The Mt. Sinai Journal of Medicine. 2002;69:404-409.
2. Ludmerer, K. Instilling professionalism in medical education. JAMA. 1999;282:881-882.
3. Swick, HM; Szenas, P; Danoff, D; Whitcomb, ME. Teaching professionalism in undergraduate medical education. JAMA. 1999;282:830-832.
4. Robins, LS; Braddock, CH; Fryer-Edwards, KA. Using the American Board of Interal Medicine's "Elements of Professionalism" for undergraduate ethics education. Academic Medicine. 2002;77(6):523-531.
5. Medical Professionalism Project: American Board of Interal Medicine Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine. 2002;136(3):243-246.
6. Ethical situation with Mr. Jones adapted from an Intersession on Professionalism given at the Medical College of Wisconsin on January 4, 2005.
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