Professionalism in Medicine: Critical Perspectives

274 Pages·2006·3.222 MB·English

by  Brian Castellani, Frederic W. Hafferty (auth.), Delese Wear, Julie M. Aultman (eds.)

Professionalism in Medicine
Critical Perspectives
Delese Wear
Julie M. Aultman
Editors
Professionalism in Medicine
Critical Perspectives
Sprin
ger
Editors:
Delese Wear, Julie M. Aultman
Northeastern Ohio Universities College of Medicine, U.S.A.
Library of Congress Cataloging-in-Publication Data
A CLP. Catalogue record for this book is available
from the Library of Congress.
ISBN 10: 0-387-32726-6 ISBN 13: 9780387327266 Printed on acid-free paper.
e-ISBN 10: 0-387-32727-4 elSBN 13: 9780387327273
Library of Congress Control Number: 2006921544
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CONTENTS
Introduction
Delese Wear and Julie M. Aultman vii
PART ONE
Conceptualizing Professionalism
1. The Complexities of Medical Professionalism: 3
A Preliminary Investigation
Brian Castellani and Frederic W. Hajferty
2. An Analysis of the Discourse of Professionalism 25
Jamie L Shirley and Stephen M, Padgett
3. Professionalism: Curriculum Goals and Meeting Their Challenges 43
David J. Doukas
PART TWO
Teaching Professionalism
4. Medical Professionalism: 63
The Nature of Story and the Story of Nature
Daniel George, lahn Gosenhauser, and Peter Whitehouse
5. Respect for Patients:
A Case Study of the Formal and Hidden Curriculum 87
Delese Wear
6. You Say Self-interest, I Say Altruism 103
Jack Coulehan
7. The Role of Ethics within Professionalism Inquiry: 129
Defining Identity and Distinguishing Boundary
Julie M. Aultman
VI
8. Medical Professionals and the Discourse of Professionalism: 149
Teaching Implications
Bradley Lewis
PART THREE
Assessing Professionalism
9. Educating for Professionalism at Indiana University 165
School of Medicine: Feet on the Ground and Fresh Eyes
Thomas S. Inui, Ann H, Cottingham,
Richard M. Frankel, Debra K. Litzelman,
David L Mossbarger, Anthony L Suchman,
T. Robert Vu, and Penelope R. Williamson
10. The Problem with Evaluating Professionalism: 185
The Case against the Current Dogma
Mark Kuczewski
11. How Medical Training Mangles Professionalism: 199
The Prolonged Death of Compassion
Cynthia Brincat
12. W/ns Not Enough 211
Audiey Kao and Jennifer Reenan
13. Professionalism and the Heisenberg Uncertainty Principle 233
Laura J, Fochtmann
Coda 255
David Leach
List of Contributors 261
Index 271
INTRODUCTION
Professionalism in Medicine: Critical Perspectives casts a careful, and at
times wary, eye on a dominant force in contemporary academic medicine
that appears to have been accepted as an absolute good. Calls for
developing, increasing, or maintaining professionalism—not to mention the
current obsession with evaluating or assessing it—appear with regularity in
medical journals and conference programs of all stripes. The resultant
literature has defined, organized, contained, and made seemingly immutable
a group of attitudes and behaviors subsumed under the label "professional"
or ''professionalism" (Wear & Kuczewski, 2004). Moreover, the fixation
with assessment has become a new steering mechanism that is reductionistic
when it shapes the total range of possible and thinkable dimensions of
professionalism. The richness, complexity, and contradictions of
professionalism in medicine are being flattened into categorical attitudes or
behaviors that evaluators (whose professionalism is rarely assessed) can
check. As Mark Kuczewski, one of the contributors to this volume, observes,
"Valuing and evaluating professionalism seem to have become equated."
This preoccupation with assessment is not indigenous to medical
education. It is arising and taking hold of many institutions as new
principles—indeed, mandates—of scrutiny and examination become
acceptable, if not desirable, cultural practices. In their incisive work on audit
cultures in higher education. Shore and Wright (2000) argue that coercive
practices of accountability sometimes sound eerily like moves toward
"exhibiting" professionalism whereby "every individual is made acutely
aware that [his] conduct and performance is under constant scrutiny" (p. 77).
This, it seems, is the direction of the professionalism movement in academic
medicine, one that focuses on attitudes and behaviors that can be taught or
sometimes modeled and thus evaluated like any other type of expertise or
"competence." Moreover, audit cultures are interested in systems that track
and indicate evidence of professional development (e.g., professional
portfolios), so that medical students can become "auditable." Such constant
surveillance for evidence or lack of professionalism becomes, according to
Foucault (1977), a means to ensure that students constantly scrutinize
themselves for confirmation that they have adopted the norms of conduct
desired by the institutions educating them. The "more difficult (and
politically charged) professionalism project of re-negotiating the social
contract between physicians, communities, and other occupational
groups"—that is, viewing professionalism as going to the heart of medical
Vlll
institutions, the profession itself, rather than unloading it on the individual
student's or resident's shoulders—is rarely part of the conversation
circulating in medical schools, associations, and other accrediting bodies
(Shirley & Padgett in this volume).
In our quest for educating virtuous, sensitive, and skilled physicians it
seems we have acceded, again, to the sirens of "economy over ecology,
counting over accountability, objectivity over subjectivity, answers over
questions, rigor over vitality, conclusions over curiosity, reduction over
production, prose over poetry, reason over emotion, fragmentation over
wholeness" (Leggo, 2005). Moreover, we have ceased careful consideration
of what we're doing once "on board" the professionalism train. The authors
here seek to slow down (if not stop) the train, asking difficult questions of us
all. Their questioning is richly diverse and sometimes at odds with each
other. They all agree that the issues underlying the recent calls for
professionalism within medicine deserve focused attention, but that may be
one of the few points of convergence. Each unravels, some more than
others, the tidy package of professionalism that is often presented in the
academic medicine literature.
In a much-needed, circumspect pause, this collection is the work of
scholars who critically examine the current professionalism "movement"
from various angles. We divide their essays into three major organizers:
professionalism as a conceptual issue, a curricular issue, and a
competency/assessment issue. However, we are quick to point out that
these categories have permeable borders: Each essay is theoretically
situated, each has curricular implications (even if not stated outright), and
each has something to suggest about the role of assessment. Still, each
essay seems to emerge from a particular critical location regarding one of
these aspects of professionalism.
The first section, professionalism as a conceptual issue, provides readers
with a convincing argument that conceptions of professionalism arise from
multiple, diverse, and sometimes conflicting theoretical orientations. In the
first chapter, "The Complexities of Medical Professionalism," Brian
Castellani and Fred Hafferty offer a radical rethinking of professionalism by
suggesting that there is not one but seven clusters of professionalism
circulating in medicine. These clusters, which arise from different ways of
organizing medical work, include nostalgic, unreflective, academic,
entrepreneurial, empirical, lifestyle, and activist professionalism, and
provide medical educators with a paradigm-shattering way to think about
what they expect of, encourage, and assess students in terms of professional
"growth." In their chapter, "An Analysis of the Discourse of
Professionalism," Jamie Shirley and Stephen Padgett examine the
IX
professionalism movement through its language, using a post-structural
analysis that recognizes language as a social practice. "Through language,"
they write, "communities reproduce their structures, discipline their
members, and enact social practices." Their position, one that radically
departs from current convention, is that professionalism efforts miss the boat
because they "locate the solutions to systematic problems of medical
education and practice in the virtues of individual physicians." The third
chapter in this section represents a traditional approach to professionalism in
academic medicine. David Doukas's "Professionalism: Curriculum Goals
and Meeting Their Challenges" begins with the assumption that the recent
mandates for professionalism by the LCME and ACGME represent the best
standards to which professionalism efforts should aspire. As a means to put
these high standards into action, he presents a model code of professionalism
for medical students, residents, and their teachers that will be formally and
openly expressed at various junctures in the medical education process.
Hopefully, readers will be struck with the wide theoretical divergence of
these three perspectives on professionalism.
Professionalism as a curricular issue is the largest section of the book.
Here authors elaborate on the content, pedagogy, and placement of
professionalism in the medical curriculum, and here also are points of
agreement and major divergence. Daniel George, lahn Gonsenhauser and
Peter Whitehouse posit in "The Nature of Story and the Story of Nature" that
professionalism efforts have largely been "more of a humanizing veneer of
platitudes and abstract definitions than an operational ethos in students'
lives." Proposing that professional development must conjoin medical and
public health, they recommend course work based on a narrative approach
where students take a central role in their own exploration of scientific and
ethical values. Delese Wear focuses more narrowly on one element of
professionalism—respect—and develops a curriculum based on a "pedagogy
of discomfort" in her chapter, "Respect for Patients: A Case Study of the
Formal and Hidden Curriculum." In place of professionalism. Jack
Coulehan suggests a more comprehensive approach, a "rebirth of medical
morality for the 21st century." In its current iteration, professionalism
"avoids grappling with deep issues of value and character formation and fails
to internalize the narrative tradition of medicine." At the end his chapter,
"You Say Self-interest, I Say Altruism," he demonstrates how fictional
narratives can contribute to the character formation of medical students.
While each arises from different perspectives, all three of the
aforementioned chapters look to literature and other narrative forms. The
next three chapters emphasize the need to step back and take a critical look
at the language and curricular practices of professionalism. In her chapter
"The Role of Ethics within Professionalism Inquiry," Julie Aultman argues
that the language of professionalism is imprecise, if not inaccurate, when
conflated with medical ethics. She notes that even among medical educators
these areas of inquiry and application are poorly understood and are
ostensibly taught under the misguided assumption that the theoretical
underpinnings of professional and ethical values and concepts are of no
importance in medical education. Aultman identifies significant distinctions
in the approaches and goals between professionalism inquiry and medical
ethics, providing clear definitions and methodologies for each, along with
practice-based boundaries between the two. Similar to the theoretical
position taken by Jamie Shirley and Steve Padgett in the first section of this
book, Brad Lewis strongly argues in his chapter, 'Medical Professionals and
the Discourse of Professionalism," that the discourse of professionalism
should be reworked to include a meaningful distinction between "the
institution of medicine as a social phenomenon and the professionalism
movement as largely focused on individual physicians." Curricular
implications here focus on "teaching the conflicts" in professionalism
whereby educators bring to the forefront the incommensurabilities embedded
in the profession by exposing students to critical scholarship that identifies
the deep problems and contradictions in contemporary medical systems.
Finally, Thomas Inui and colleagues describe a dramatic, systemic,
environmental change that "attempts to change the culture of a large medical
school and, therefore, align the formal and the informal curricula." Their
chapter, "Educating for Professionalism at Indiana University School of
Medicine," delineates how professionalism education takes place in a
competency-directed curriculum, and like other competencies, "is considered
to be an explicit objective of every required experience a student has at
lUSM."
Four chapters complete the last section of the book, which focuses on
professionalism as a competency/assessment issue. In "The Problem with
Evaluating Professionalism," Mark Kuczewski elaborates on just that: "The
desire for objective assessment is determining how medical education
construes professionalism." To that end, the most seemingly objective
assessments are those more likely to document unacceptable behaviors rather
than to encourage positive ones. And rather than focus all attention on the
former, he suggests ways to demonstrate how medical educators value
professionalism in the medical school and clinical environments. Cynthia
Brincat, a philosopher turned physician, provides a critically reflective first-
person account of the professionalism efforts she has experienced and
observed as a student and resident. In her chapter, "How Medical Training
Mangles Professionalism," Brincat develops the idea that the
"professionalism crisis in medicine is, in many ways, manufactured."
Moreover, she argues, this "disease" model of professionalism actually