Early in the development of contemporary bioethics, educators developed the attitude that philosophically rigorous bioethics had, in an important sense, supplanted traditional medical ethics, which was couched in terms of virtues and duties specific to the medical profession. Traditionally, concepts such as patient self-determination, rights and justice played either no role or only a derivative one, whereas in philosophical bioethics these concepts are primary. The system of ethical principles is applicable to all, doctors and patients alike. In this context, teaching of professional virtue quickly disappeared from medical school curricula. While some medical ethicists continued to write about professional virtue1^–4, principle-based bioethics became the centerpiece of medical curricula.5 The moral dimensions of professionalism suffered so much of a decline that in 1989 Larry Churchill wrote, “How did we get to this point of not valuing a distinctive professional ethic? A profession without its own distinctive moral convictions has nothing to profess.”6

In recent years, medical professionalism has had a dramatic rebirth. In response to the perception that contemporary physicians have lost their commitment to professional behaviour, the Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, American College of Physicians and other organisations have initiated major programs to teach and evaluate professionalism among students and residents.7^–10 However, these curricula face an uphill battle. In a comprehensive 2003 report, Thomas Inui concluded that although a virtual consensus on the qualities of medical professionalism exists, “what the literature and rhetoric of medicine lacks is a clear recognition of the gap between these widely recognized manifestations of virtue in action and what we actually do in the circumstances in which we live our lives” (p4).11 He concludes that “additional courses on medical professionalism are unlikely to fundamentally alter this regrettable circumstance. Instead, we will actually have to change our behaviors, our institutions, and our selves”(p5).11

To accomplish this, we need to change the culture of medical education by instituting broad (and deep) narrative professionalism curricula throughout medical education. I use the term narrative-based professionalism to refer to that tradition that values, beliefs and community are essential to medical professionalism.12 But unless they are manifest in physicians’ personal stories, such concepts are impotent. For medical professionalism to mould the behaviour of physicians in training, it must be formulated as a meta-narrative—a summation of, and reflection upon, many thousands of actual physicians’ stories from different times and cultures, as well as multiple contemporary narratives, observed either directly in role model physicians and other health professionals or indirectly in stories and film. In other words, narrative professionalism requires entering into a certain narrative ethos and publicly affirming that ethos in word and deed.

This contrasts with what I call rule-based professionalism, which consists of objectives, competencies and measurable behaviours that are intended to delineate professionalism, but not necessarily from the ground up (ie, arising from a narrative ethos).12 Dichotomising these two types of professionalism has heuristic value, although neither exists in pure form. Given the current state of medical education, in which there is a wide gap between professed values and clinical behaviour, explicit professionalism curricula are more likely to foster rule-based interpretations than to embody the full narrative tradition.12^–14 Alternatively, to achieve substantial culture change in medical education, we will need a broad curricular realignment that includes extensive narrative role modeling and a commitment to self-awareness, narrative competence and community service.

NARRATIVES OF PROFESSIONAL VIRTUE

The study of creative literature can contribute to medical education in many ways.15^–17 Among these is the nourishment of narrative competencies—for example, “the capacity to adopt others’ perspectives, to follow the narrative thread of complex and chaotic stories, to tolerate ambiguity and to recognize the multiple, often contradictory meanings of events that befall human beings” (p788).15 In the context of professionalism education, study of fictional (and non-fictional) narratives can contribute to all four components of the narrative professionalism “package” just described. Obviously, creative literature plays only a supplemental role in professional character formation. Nonetheless, it can serve to broaden the student’s range of role models, to enhance self-awareness, to stimulate social responsibility and to expand and deepen the student’s narrative competence. In the following examples, I want to illustrate how four short stories I frequently teach might help medical students explore the meaning of professionalism from a narrative perspective.

NARRATIVE-BASED VERSUS RULE-BASED PROFESSIONALISM

In Mikhail Bulgakov’s “The Steel Windpipe”, a young physician with hardly any experience finds himself in charge of a small community hospital.18 One of his first patients is a young girl brought to the hospital by her mother and grandmother. She is terrified because she can’t breathe. The doctor quickly ascertains that the girl has diphtheria, which has progressed to the point of near-total tracheal obstruction. He struggles to maintain a calm demeanor despite the anger he feels at the patient’s mother and grandmother, who waited 5 days before bringing the child to the hospital for treatment.

With his patient on the verge of death, the doctor decides that only an emergency tracheotomy can save her. But there are two problems. First, the grandmother distrusts doctors and violently opposes surgery; she convinces the mother not to consent. In response to her refusal, the young physician completely loses his cool. He denounces the grandmother’s advice, threatens the mother with her child’s death and finally begs her to agree to the tracheotomy. The second problem is that the doctor actually realises that he is in way over his head. Despite his insistence on aggressive care, he has never performed the procedure and is afraid that he might kill the girl if he attempts a tracheotomy. Nonetheless, under his intense pressure the mother finally agrees, and the doctor quickly performs the surgery and inserts a tracheostomy tube (“steel windpipe”). The outcome is marvelous: the little girl breathes freely; her crisis passes; her life is saved.

“The Steel Windpipe” is a classic tale of the doctor-as-saviour.17 In many years of teaching this story to first-year medical students, I’ve rarely encountered one who wasn’t stirred by the hero’s performance. These future physicians find it easy to visualise themselves performing such heroic acts. They see themselves as doing whatever it takes to save their patients’ lives, even if involves the “tough love” of breaking rules and battering parental superstition. Of course, as their clinical training proceeds, this romantic vision quickly fades. Nonetheless, preclinical students respond to “The Steel Windpipe” and to other, similar Bulgakov stories such as “Baptism by Rotation” and “The Embroidered Towel” with unbridled enthusiasm. They realise intuitively that heroic action requires the whole person, that it takes more than mere technical training to resolve a crisis. The physician also needs integrity, courage, quick thinking and the ability to function in the face of conflict, pressure and strong emotion.

But how professional is the behaviour of Bulgakov’s young doctor? Does he act like a responsible physician in saving this little girl’s life? He would perhaps remain a hero if we transferred him from a hospital in revolutionary Russia to a contemporary episode of ER on television, although we might expect some muttering in the background about him being a “loose cannon”. But how would his behaviour be judged in a real-life emergency room? Does he demonstrate medical professionalism? Well, yes and no. The doctor in “The Steel Windpipe” demonstrates courage, decisiveness, beneficence and compassion. However, he fails miserably with regard to prudence, and he is disrespectful of his patient’s mother and grandmother. He allows his anger to show, uses coercive techniques to obtain consent and undertakes a procedure that he is inadequately trained to perform. If the tracheotomy had gone wrong, or the girl had died in spite of it, we could just as well use the story to illustrate the danger of unprofessional behaviour such as overstepping one’s level of competence and using coercive techniques to obtain consent.

Thus, the doctor demonstrates virtues we tend to value highly in urgent medical situations, but he also runs roughshod over many of the rules of professionalism. Let me contrast Bulgakov’s hero with another physician from Russian literature. In Anton Chekhov’s short story called “Darkness”, a distraught peasant approaches a rural doctor to beg for a favour.19 The man’s brother was sent to prison for breaking into a bakery. There were extenuating circumstances: the brother was drunk at the time and didn’t mean any harm. Could the doctor use his influence to get the man’s brother released? At first, the doctor explains that he has no influence over the legal system; there is simply nothing he can do. However, the peasant won’t give up. He hounds the doctor until the latter becomes so enraged he slams the door in the man’s face.

Medical students find this fictional physician despicable. They immediately point out his insensitivity, arrogance, dismissiveness and lack of empathy. However, when one looks carefully at the question of his professionalism, the answer is not so straightforward. First of all, the doctor does take the time to speak to this man who approaches him on the street. Second, he is truthful—in fact, medical doctors do not have power over the judiciary—and he also provides a reasonable suggestion—that the man take his request to the district court. Finally, neither the supplicant nor his brother is this particular doctor’s identified patient. In fact, Chekhov’s doctor adheres to most of the relevant canons of professionalism, except in the end when he becomes angry at his supplicant’s persistence. So why do the students have such a negative reaction?

For one thing, although the doctor in “Darkness” obeys the rules, he does not demonstrate the kind of virtue we like to see in our doctors. He fails to act in a recognisably compassionate manner. He refuses to advocate for this poor ignorant fellow who, after all, has petitioned him for help. (Some may even feel that the fact of their speaking together constitutes the initiation of a doctor–patient relationship.) And finally, when the doctor eventually gets angry, he acts in an abrupt and arrogant manner. We don’t like the character, and yet it is difficult to specify precisely what is unprofessional in his behaviour.

The students’ responses to these two fictional physicians serve to illustrate a difficulty with using rule-based professionalism as the standard for medical virtue and, consequently, with the attempt to re-energise (or rehumanise) medical education by introducing explicit professionalism curricula. The current program begins by setting forth lists of behavioural norms for physicians; the norms are drawn from professional ethics, which, in turn, is based on a mixture of tradition, social etiquette, religious values and philosophy, primarily virtue theory—in essence, a comprehensive moral vision of medicine. For the sake of argument, let’s say that the new professionalism movement depends very heavily on the lists and is very light on the comprehensive moral vision. In this case, students will find that the program lacks energy and feels rather sterile to them. But because they are pragmatists, they will adopt the rules and get on with their careers. This form of competency-based professionalism may well produce doctors who know and obey the professional rules but, like Chekhov’s character in “Darkness”, don’t embody the true spirit of professionalism. Following the rules does not necessarily make a good (or humane or admirable) physician.

However, if you define professionalism as a more comprehensive moral vision of medicine—for example, the virtue-based moralities of medicine developed by Pellegrino and Thomasma1, Drane20, Sulmasy21 and Coles22—rather than simply as a set of rules, you run into another problem. You attribute various virtues or attributes to “good” doctors—for example, the good doctor has integrity, compassion, courage, fidelity, humility and so on. To be a good doctor, the trainee must develop these virtues, so you need a professionalism curriculum to facilitate that process. But how? How do we teach virtues in medical school? And if it is possible to teach them, how much (what quantity) of a given virtue is required before the trainee can be considered sufficiently virtuous? Let’s say compassion and beneficence are virtues that predispose me to advocate for my patients, a posture that in some cases will demand that I put the patients’ best interests before my own. Thus, these virtues do have behavioural consequences that we can measure—for example, advocating for a patient with an insurance bureaucrat, or spending extra time with an anxious patient when you could have gone home for supper. But how much advocacy is enough? Or how many hours are enough? It isn’t clear whether we can structure medical education to teach virtue, but even if we can, I doubt if reasonable physicians could all agree on the “target” levels of virtuousness.

Bulgakov implies a connection between the character of the newly minted physician and his successful intervention to save the child. The safe path would have been a more conventional, less risky, course of treatment. If he had then lost the patient, the death would have occurred within the safe haven of an established protocol. He would have got through the morbidity and mortality conference with flying colours. But the doctor put his self-esteem as well as his reputation on the line for the benefit of the little girl, a course that exposed her to significant risk. He was successful, but what if she had died in any case? In some ways, this is a clear example of character (narrative) versus rules.

MORE AMBIGUOUS NARRATIVES OF DOCTORS

Other stories provide more ambiguous physician role models. For example, Marfa Petrovna Petchonkin in Chekhov’s “Malingerers”23 is a very likeable woman with a “good” character, but is she a good physician? Certainly, her patients think so. Marfa is a homeopath who conducts her practice in a home office. One middle-aged man had had rheumatism for 8 years while other doctors “did me nothing but harm”. “All they care about is their fees, the brigands; but as for the benefit of the community—for that they don’t care a straw.”23 Allopathic physicians prescribe pills and potions, but they never get to the root of the problem. Rather, they just suppress the symptoms. Worse yet, they may complicate the problem by treating too aggressively. Not so, however, with Dr Petchonkin, who pursues a simple and gentle homeopathic philosophy.

Students usually take a liking to Dr Petchonkin, in part because of her opposition to the aggressive and useless medical treatments of her day. They are intrigued and amused by her embrace of homeopathy. It seems clear at first that she achieves her “cures” by interpersonal factors, by using the doctor–patient relationship to benefit her patients. The positive feelings are mutual; Dr Petchonkin seems to thrive on her patients’ gratitude. Perhaps their gratitude is too important to her. In fact, a closer reading of the story raises serious questions about this doctor’s professionalism. She not only “cures” her patients, but also gives them gifts and favours, such as offering to pay for a daughter’s education. In such behaviours, Marfa moves beyond the bounds of medical professionalism to a level of nurturing more appropriate to intimate friendship and hence unstructured and open-ended. Marfa displays an intuitive perception of the connection between care and healing. However, she evidently allows emotional attachment to undermine clinical distance and objectivity. Thus, this superficially virtuous physician poses a serious problem. What happens when a physician confuses professional and personal relationships?

Yet a boundary problem, perhaps even a serious one, need not necessarily prevent a person from being a good doctor. In Susan Mate’s “The Good Doctor”, middle-aged Dr Helen van Horne has devoted her career to unselfishly caring for poor persons who otherwise lack access to medical care.24 For many years she practiced in rural East Africa; more recently she serves as Chief of the Department of Medicine at City Hospital in the South Bronx. Van Horne is a tough, no-nonsense woman who evidently gave up the comforts of marriage and family to devote herself to her profession. While the patients in the South Bronx initially dismiss her as another white do-gooder, they soon learn to respect her as a model of rectitude, dedication and compassion. The Hispanic chief resident at City Hospital finds her an ideal role model.

Nonetheless, Dr van Horne has an Achilles heel. Her inner yearning for human comfort and sexual gratification draw her into intimate sexual contact with a lazy, irresponsible, but charming male medical student, who intends to “use” her to pass his clerkship. As a result, Dr van Horne first tells the failing student that she will give him the passing grade he doesn’t deserve, but later she realises the extent of her weakness and allows his actual grade to be recorded.

Medical students’ responses to this story vary. A few students latch tightly to Dr van Horne’s egregious behaviour—having sex with her student—condemn her for that and then generalise to impugn the motivation for her life’s work. In their opinion, she isn’t really courageous, compassionate and altruistic; she is really a power junkie, who “gets off” on lording it over the less fortunate. This cynical viewpoint, or at least a milder version of it, is widespread in our society. We apparently love to poke holes in the character of any virtuous or person we come across and, thereby, provoke a scandal—for example, MOTHER THERESA DISCOVERED TO HAVE SMOKED CIGARETTES!

The majority of students, however, take a more nuanced approach. They agree that Dr van Horne has generally been a good person and a good physician, but they struggle with the implications of her recent peccadillo. How reflective was it of her overall character? What kind of relationships might she have had with subordinates in the past? On other occasions might she have performed unethical actions when influenced by someone preying on her lack of companionship and loneliness? “The Good Doctor” presents a more complicated picture of character than either of the earlier stories. It illustrates that virtue and character interact with, and are ways of looking at, the texture of one’s personal narrative, rather than being separate and unchanging qualities.

CONCLUSIONS

After more than a generation of neglect in medical education, professionalism has been restored to the classroom and clinic. Unfortunately, additional courses, exercises, guidelines, rules or seminars on professionalism are unlikely to be successful in changing physicians’ behaviour unless embedded in an ethos that the trainee fully internalises—in other words, unless professionalism is grounded in the meta-narrative of medicine as evidenced in the lived experience of its practitioners, instead of in rules, guidelines and oaths. In earlier work, I suggested that major initiatives in role modeling, self-awareness, narrative competence and community service will be necessary to change today’s culture of medicine, which in fact fosters individualistic rather than professional values (for example, self-interest rather than altruism).12

Fictional and non-fictional written narratives can play an important supplemental role throughout medical training by introducing additional role model physicians and, more importantly, by promoting discussion and analysis of professional virtue in practice. Short stories such as “The Steel Windpipe”, “Darkness”, “Malingerers” and “The Good Doctor” illustrate the complexity of the moral dimension of medicine and the importance of self-awareness and moral imagination in the development of a professional identity.