Teaching medical students professionalism: what role for the medical humanities?
- Richard Meakin, Department of Primary Care & Population Sciences, Royal Free and University College Medical School, Hampstead Campus, Rowland Hill Street, London NW3 2PF, UK;
Medical educators are charged with the task of educating students in medical professionalism. This task poses a number of questions. The most fundamental of these is what is meant by medical professionalism in the 21st century? This is closely followed by the two questions, how should we teach this? and how should we assess our students? As medical educators involved in the medical humanities, we clearly have another question to consider: how can the medical humanities contribute to this task?
During the second half of the 20th century and the early years of this century, many things changed in the relationship between doctors and society in the developed world. A large number of effective therapeutic interventions have been developed. This, together with an ageing population with an increasing burden of chronic health problems, has resulted in competing demands for the limited financial resources available for healthcare. Societal values now emphasise personal autonomy and consumerism. Information about illness and disease is more available to people via the media and the internet. Both patients’ expectations about the care they will receive and doctors’ expectations of what it means to be a doctor have changed. Set against this background, a number of high-profile cases, such as the scandal of organ retetntion at the Alder Hey Hospital and the murdering of patients by Harold Shipman, have damaged society’s trust in doctors and resulted in calls from the media and politicians for greater regulation of doctors. The result has been a renewed interest among regulators, doctors, educators and researchers in the nature of medical professionalism in the 21st century.
In recent years there have been publications from regulatory bodies1 and professional societies,2 3 and qualitative empirical research involving patients, lay professionals, medical students, doctors, allied health professionals and medical educators,4 5 that have attempted to operationalise the concept of medical professionalism for the 21st century. Similar themes were identified both in the reports of regulatory body and professional societies and in empirical research that emphasise the primacy of patient welfare, respecting patient autonomy, working in partnership with patients, commitment to professional competence, honesty, commitment to patient confidentiality, maintaining an appropriate relationship between doctors and patients, individual responsibility, appropriate accountability, continuous improvement and team-working. But can scholarship in the medical humanities contribute to our understanding of the operationalisation of medical professionalism in the 21st century? Recent work such as that by Rees and Knight on unprofessional behaviour suggests that useful insights into medical professionalism can be gained from such scholarship.6
While regulatory bodies7 and professional societies2 3 believe that medical professionalism should be taught, Coulehan has questioned whether it can be taught, at least if this educational process is rule-based.8 He proposes that the usual rule-based professionalism should be replaced by narrative-based professionalism that uses role modelling, fostering self awareness, fostering narrative competence and socially relevant service oriented learning. A recent systematic review supports his view, finding only scant evidence that current educational programs designed to facilitate students’ attitudes towards professionalism are successful.9 In his paper in this issue of the journal, he describes the use of short stories as one vehicle for developing narrative-based professionalism.10 This is seen as a way of providing additional role models and promoting discussion and thus teaching the first three of his four aspects of narrative-based professionalism. While this pedagogical method is intellectually coherent and could be expected to address some of the shortcomings of a rule-based professionalism education, as medical educators we are bound to ask the question, is it any more successful at inculcating the attitudes, virtues and behaviours society expects of its doctors? This change of approach also raises the question of how medical professionalism should be assessed.
While there is little evidence that existing methods of assessment are effective in assessing attitudes towards professionalism in medicine as a whole,9 the paradigm of education suggested by Coulehan8 poses additional challenges. Narrative-based medical professionalism surely requires that narrative competency is assessed. The challenge for medical educators is to devise a valid and reliable way of assessing this. Can our colleagues from the humanities help?