A professionalism program in medical education and training - From broad values to specific applications: YLL School of Medicine, Singapore.

The process for introducing and developing a program for teaching medical professionalism at the National University of Singapore, School of Medicine is outlined. Professionalism was recognised as embracing 'honesty and integrity,' 'responsibility and participation,' 'respect and sensitivity,' and 'compassion and empathy.' Those broad values are expressed as specific attitudes and behaviours that are taught and assessed throughout the course. Honesty and integrity, for example, are demonstrated by 'presenting original, authentic assignments' (in medical education); and 'accepting personal mistakes and honestly acknowledging them' (in clinical training and practice). Values and items of behaviour were drawn from the literature, and reviewed and refined to address needs identified within the Medical School. A broad spectrum of pre-clinical and clinical teachers contributed to this development. The program was reassessed to determine the extent to which it has been implemented and has evolved following its adoption. The results are confirming in that: the majority of recommendations have been implemented; the program has developed further; and is supported by ancillary student enrichment activities. Medical professionalism has been given prominence through all phases of the course. Nevertheless, challenges remain and particularly in the extent to which medical professionalism is taught and assessed in various clinical postings.

Verbatim Theater: Prompting Reflection and Discussion about Healthcare Culture as a Means of Promoting Culture Change.

Problem: The mistreatment of medical and nursing students and junior health professionals has been reported internationally in research and the media. Mistreatment can be embedded and normalized in hierarchical healthcare workplaces, limiting the effectiveness of policies and reporting tools to generate change; as a result, some of those who experience mistreatment later perpetuate it. We used a novel, creative approach, verbatim theater, to highlight the complexity of healthcare workplaces, encourage critical reflection, and support long-term culture change. Intervention: Verbatim theater is a theater-for-change documentary genre in which a playscript is devised using only the words spoken by informants. In 2017, 30 healthcare students and health professionals were recruited and interviewed about their experience of work and training by the multidisciplinary Sydney Arts and Health Collective using semi-structured interviews. Interview transcripts became the primary material from which the script for the verbatim theater play 'Grace Under Pressure' was developed. The performing arts have previously been used to develop the communication skills of health professional students; this esthetic expression of the real-life effects of healthcare workplace culture on trainees and students was implemented to stimulate consciousness of, and dialogue about, workplace mistreatment in healthcare work and training. Context: The play premiered at a major Sydney theater in October 2017, attended by the lay public and student and practicing health professionals. In November 2017, three focus groups were held with a sample of audience members comprising healthcare professionals and students. These focus groups explored the impact of the play on reflection and discussion of healthcare culture and/or promoting culture change in the health workplace. We analyzed the focus group data using theoretical thematic analysis, informed by Turner's theory of the relation between 'social' and 'esthetic' drama to understand the impact of the play on its audience. Impact: Focus group members recognized aspects of their personal experience of professionalism, training, and workplace culture in the play, Grace Under Pressure. They reported that the play's use of real-life stories and authentic language facilitated their critical reflection. Participants constructed some learning as 'revelation,' in which the play enabled them to gain significant new insight into the culture of health care and opened up discussions with colleagues. As a result, participants suggested possible remedies for unhealthy aspects of the culture, including systemic issues of bullying and harassment. A small number of participants critiqued aspects of the play they believed did not adequately reflect their experience, with some believing that the play over-emphasized workplace mistreatment. Lessons Learned: Verbatim theater is a potent method for making personal experiences of healthcare workplace and training culture more visible to lay and health professional audiences. In line with Turner's theory, the play's use of real-life stories and authentic language enabled recognition of systemic challenges in healthcare workplaces by training and practicing health professionals in the audience. Verbatim theater provides a means to promote awareness and discussion of difficult social issues and potential means of addressing them.

Balancing bioethics by sensing the aesthetic.

This article is critical of "bioethics" as it is widely understood and taught, noting in particular an emphasis given to philosophical justification, reason and rationality. It is proposed that "balancing" bioethics be achieved by giving greater weight to practice and the aesthetic: Defined in terms of sensory perception, emotion and feeling. Each of those three elements is elaborated as a non-cognitive capacity and, when taken together, comprise aesthetic sensitivity and responsiveness. This is to recognise the aesthetic as a productive element in bioethics as practice. Contributions from the philosophy of art and aesthetics are drawn into the discussion to bring depth to an understanding of "the aesthetic". This approach is buttressed by philosophers - including Foucault and 18th century German philosophers (in particular Kant) - who recognized a link between ethics and aesthetics. The article aims to give substance to a claim that bioethics necessarily comprises a cognitive component, relating to reason, and a non-cognitive component that draws on aesthetic sensibility and relates to practice. A number of advantages of bioethics, understood to explicitly acknowledge the aesthetic, are proffered. Having defined bioethics in conventional terms, there is discussion of the extent to which other approaches to bioethics (including casuistry, virtue ethics, and narrative ethics) recognize aesthetic sensitivity in their practice. It is apparent that they do so to varying extents although not always explicitly. By examining this aspect of applied ethics, the paper aims to draw attention to aesthetic sensitivity and responsiveness as integral to ethical and effective health care.

Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students.

A positive and respectful learning environment is fundamental to the development of professional identities in healthcare. Yet medical students report poor behaviour from healthcare professionals that contradict professionalism teaching. An interdisciplinary group designed and implemented a drama-based workshop series, based on applied theatre techniques, to help students develop positive professional qualities and interpersonal skills to deal with challenges in the healthcare setting. We piloted the workshops at the University of Sydney in 2015. Attendees completed evaluation questionnaires and participated in a focus group or interview. Of 30 workshop attendances, there were 29 completed questionnaires and three participants attended a focus group or interview. Workshop activities were rated as 'very good' or 'good' by 21/22 (95.5%). Thematic analysis of qualitative data highlighted the rationale for participation (to deal with bullying, prevent becoming a bully, learn social skills), workshop benefits (express emotions, learn about status dynamics and deconstructing personalities, empathy, fun), challenges (meeting participants' expectations, participants' need for further practice) and implications for medical education (need to develop awareness of others' perspectives). Our research has shown that there is momentum to challenge mistreatment in medical education. While a multipronged approach is needed to generate systemic change, this pilot offers a positive and creative innovation. It helps students improve their interpersonal skills and sense of self to deal with challenges in the healthcare setting, including mistreatment.

Globalisation, economics and professionalism.

This paper presents an analysis of the effect of globalisation and attendant economic factors on the global practice of medicine, medical education, medical ethics and medical professionalism. The authors discuss the implications of these trends, citing case scenarios in the healthcare insurance, medical tourism, pharmaceutical industries, and the educational systems as well as in clinical practice, to illustrate the impact of globalisation and economics on professionalism. Globalisation, on the one hand, offers benefits for the global practice of medicine and for medical education. On the other, globalisation can have negative effects, particularly when the main driver is to maximise profitability across national boundaries rather than concern for human well-being. Appraising the effect of globalisation on professionalism involves assessing its effects at the intrapersonal, interpersonal, and institutional levels, and its effect on society at large.

Response-A Critical Response to "Discourse Communities and the Discourse of Experience".

In their article Little, Jordens, and Sayers developed the notion of "discourse communities"-as groups of people who share an ideology and common "language"-with the support of seminal ideas from M.M. Bakhtin. Such communities provide benefits although they may also impose constraints. An ethical community would open to others' discourse and be committed to critique. Those commitments may counter the limitations of discourse communities. Since their paper was published in 2003, the notion of "discourse communities" has been widely adopted and applied in healthcare and beyond. Their ideas were influential in the founding of an ethics centre in Sydney and contributed to articulating the values which underpin this journal. This commentary notes that an ethical community is fragile in responding to current onslaughts on truth and meaning-potencies inherent in discourse communities. The essay takes Bakhtin's ideas further to explore intrinsic forces at play in dialogue, language, and art. This leads to discussing the centrality of ethics in Bakhtin's thought. For him, the essence of discourse is a dialogic exchange which comprises both art and ethics. It is art in that self and other are created in the exchange. It is ethical in that "I" am answerable to the other, as a phenomenological reality, in the moment of intersubjectivity.

The arts and medicine: a challenging relationship.

This paper discusses various justifications for including medical humanities and art in healthcare education. It expresses concern about portrayals of the humanities and art as benign and servile in relation to medicine and the health professions. An alternative is for the humanities to take a more active role within medical education by challenging the assumptions and myths of the predominant biomedical model. Another is to challenge quiescent notions of the arts by examining examples of recent provocative work and, to this end, the paper considers the work of performance artists Stelarc and Orlan who have subjected their bodies to modifications and extensions. Their work challenges, and potentially undermines, conceptions of the body, medicine, and humanity's relationship with technology. Similarly, other artists, working with biological cultures, have raised controversial issues. Recent work of this kind defies easy understanding and resists being pressed into the service of medicine and other health professions for educational purposes by opening up topics for exploration and discussion without providing unitary explanatory frameworks. The paper goes on to discuss the implications for medical education if this is the approach to the arts and humanities in healthcare education. It suggests that there needs to be a shift in the foundational assumptions of medicine if the arts and humanities are to contribute more fully.

A Response to "Fragile Objects".

This is a critical response to "Fragile objects: A visual essay," by Chapman et al. published in the Journal of Bioethical Inquiry (2019, 16(2): 185-189). Whilst "Fragile objects" is evocative of the author(s)' experience in sitting with a man ("Patrick"), who had been diagnosed with Alzheimer's, I express concern that there are unwarranted and unsubstantiated conclusions drawn about Patrick's phenomenological experience of dementia/Alzheimer's.

Access to high cost medicines in Australia: ethical perspectives.

Access to "high cost medicines" through Australia's Pharmaceutical Benefits Scheme (PBS) is tightly regulated. It is inherently difficult to apply any criteria-based system of control in a way that provides a fair balance between efficient use of limited resources for community needs and equitable individual access to care. We suggest, in relation to very high cost medicines, that the present arrangements be re-considered in order to overcome potential inequities. The biological agents for the treatment of rheumatoid arthritis are used as an example by which to discuss the ethical issues associated with the current scheme. Consideration of ethical aspects of the PBS and similar programs is important in order to achieve the fairest outcomes for individual patients, as well as for the community.