Medical professionalism: what the study of literature can contribute to the conversation.

Medical school curricula, although traditionally and historically dominated by science, have generally accepted, appreciated, and welcomed the inclusion of literature over the past several decades. Recent concerns about medical professional formation have led to discussions about the specific role and contribution of literature and stories. In this article, we demonstrate how professionalism and the study of literature can be brought into relationship through critical and interrogative interactions based in the literary skill of close reading. Literature in medicine can question the meaning of "professionalism" itself (as well as its virtues), thereby resisting standardization in favor of diversity method and of outcome. Literature can also actively engage learners with questions about the human condition, providing a larger context within which to consider professional identity formation. Our fundamental contention is that, within a medical education framework, literature is highly suited to assist learners in questioning conventional thinking and assumptions about various dimensions of professionalism.

Transforming educational accountability in medical ethics and humanities education toward professionalism.

Effectively developing professionalism requires a programmatic view on how medical ethics and humanities should be incorporated into an educational continuum that begins in premedical studies, stretches across medical school and residency, and is sustained throughout one's practice. The Project to Rebalance and Integrate Medical Education National Conference on Medical Ethics and Humanities in Medical Education (May 2012) invited representatives from the three major medical education and accreditation organizations to engage with an expert panel of nationally known medical educators in ethics, history, literature, and the visual arts. This article, based on the views of these representatives and their respondents, offers a future-tense account of how professionalism can be incorporated into medical education.The themes that are emphasized herein include the need to respond to four issues. The first theme highlights how ethics and humanities can provide a response to the dissonance that occurs in current health care delivery. The second theme focuses on how to facilitate preprofessional readiness for applicants through reform of the medical school admission process. The third theme emphasizes the importance of integrating ethics and humanities into the medical school administrative structure. The fourth theme underscores how outcomes-based assessment should reflect developmental milestones for professional attributes and conduct. The participants emphasized that ethics and humanities-based knowledge, skills, and conduct that promote professionalism should be taught with accountability, flexibility, and the premise that all these traits are essential to the formation of a modern professional physician.

The challenge of promoting professionalism through medical ethics and humanities education.

Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.

Perspective: Medical education in medical ethics and humanities as the foundation for developing medical professionalism.

Medical education accreditation organizations require medical ethics and humanities education to develop professionalism in medical learners, yet there has never been a comprehensive critical appraisal of medical education in ethics and humanities. The Project to Rebalance and Integrate Medical Education (PRIME) I Workshop, convened in May 2010, undertook the first critical appraisal of the definitions, goals, and objectives of medical ethics and humanities teaching. The authors describe assembling a national expert panel of educators representing the disciplines of ethics, history, literature, and the visual arts. This panel was tasked with describing the major pedagogical goals of art, ethics, history, and literature in medical education, how these disciplines should be integrated with one another in medical education, and how they could be best integrated into undergraduate and graduate medical education. The authors present the recommendations resulting from the PRIME I discussion, centered on three main themes. The major goal of medical education in ethics and humanities is to promote humanistic skills and professional conduct in physicians. Patient-centered skills enable learners to become medical professionals, whereas critical thinking skills assist learners to critically appraise the concept and implementation of medical professionalism. Implementation of a comprehensive medical ethics and humanities curriculum in medical school and residency requires clear direction and academic support and should be based on clear goals and objectives that can be reliably assessed. The PRIME expert panel concurred that medical ethics and humanities education is essential for professional development in medicine.

Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner.

Abraham Flexner was commissioned by the Carnegie Foundation for the Advancement of Teaching to conduct the 1910 survey of all U.S. and Canadian medical schools because medical education was perceived to lack rigor and strong learning environments. Existing proprietary schools were shown to have inadequate student scholarship and substandard faculty and teaching venues. Flexner's efforts and those of the American Medical Association resulted in scores of inadequate medical schools being closed and the curricula of the survivors being radically changed. Flexner presumed that medical students would already be schooled in the humanities in college. He viewed the humanities as essential to physician development but did not explicitly incorporate this position into his 1910 report, although he emphasized this point in later writings. Medical ethics and humanities education since 1970 has sought integration with the sciences in medical school. Most programs, however, are not well integrated with the scientific/clinical curriculum, comprehensive across four years of training, or cohesive with nationally formulated goals and objectives. The authors propose a reformation of medical humanities teaching in medical schools inspired by Flexner's writings on premedical education in the context of contemporary educational requirements. College and university education in the humanities is committed to a broad education, consistent with long-standing tenets of liberal arts education. As a consequence, premedical students do not study clinically oriented science or humanities. The medical school curriculum already provides teaching of clinically relevant sciences. The proposed four-year curriculum should likewise provide clinically relevant humanities teaching to train medical students and residents comprehensively in humane, professional patient care.

Teaching bioethics at (or near) the bedside.

Many teachers of bioethics often express concern, in their writings and otherwise, about the theoretical basis (or lack of it) of bioethics and the allied issue of relativism. The companion articles by Tong and Momeyer are in this vein and rightly address such issues within the context of a liberal arts education. This article addresses such issues in a different venue, i.e., bioethics teaching in the clinical sphere of health care institutions. It presumes to suggest that many of these theoretical concerns, as well as the threat of relativism, seldom arise in this sphere. Rather, a broad based, well accepted body of moral truth has been fashioned over the last quarter century and it is this that clinical bioethics regularly keys to and to which most moral dilemmas are referred for resolution. The various forms of this pedagogy, e.g., case consultations or institutional policy statements, are charted out in this regard, as well as the often tactical character of much of this teaching, i.e., not "what should we do?", but "how might we best do it?". The article then goes on to conclude with a reflection on the use and abuse of power in clinical bioethics teaching and consultation.

Clinical ethics and the suffering Christian.

Contrary to the ecumenical spirit of our time, the differences among the Christian religions bring into question what one can say or do in common with fellow Christians. This issue, echoing the program of this journal, accentuates those differences, specifically when we focus on the Christian who is ill and suffering. At the bedside, it is the specifics of a religion, including not only its doctrines, but its informing and sustaining narratives, that must particularly be brought into play for the sake of the patient. Given this, our focus in this article regards what such a view implies for the clinician who is caring for a Christian patient whose religion he may or may not share, in general or in its specifics. Our basic conclusion is that the tendency for the clinician to act as both the patient's spiritual counselor, as well as his clinician, is generally neither prudent nor appropriate. Both hats should not be worn concurrently. This view is advanced not only because of concerns regarding patient vulnerability and the possible abuse of power, but also because the two roles may collide with or undermine each other.