By MIKE MAGEE, MD
As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
“From my own perspective, I have no reservations about accepting any, or all of the foregoing articulations of various qualities, attitudes, and activities of the physician as legitimate representations of important attributes for the trustworthy professional. In fact, I find it difficult to choose one list over others, since they each in turn seem to refer largely to the same general set of admirable qualities. While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”
Later in the report, he shared: “The processes of formation include experience and reflection, service, growth in knowledge of self and of the field, and constant attention to the inner life as well as the life of action. ‘Who am I becoming as I move towards this life of service?’” My good friend, Fitz Mullan, the inspiration for the Beyond Flexner Alliance focused on the social mission in health professions education, was quick to remind me some years back that an equally important question is: “Why am I becoming that?”
In the same year when Dr. Inui was doing his AAMC fellowship, John Iglehart, founding editor of Health Affairs, interviewed Steven Schroeder, who had announced his coming retirement as CEO of the Robert Wood Johnson Foundation. Schroeder said, “If physicians and nurses, who are central to the operation of the system, however care is financed, are dissatisfied and feel undervalued, I grieve for that system because that is a system in trouble.” Here we see a shift, away from “I” to “it”. It is the “system”, not an individual or even an individual’s teachers, that is “in trouble”. “Bad people or bad design?”, W. Edwards Deming might ask.
Here is the troublesome question that underpins the need for “Advanced Professionalism”: What if our failings in ‘professionalism’ are more fundamental and foundational? Might they be the result of a non-adaptive and ancient system – still centered on a brick and mortar “hospital-medical office loop”; still backward facing and reacting to illness rather then forward-facing and managing customized and personalized strategic health planning; still over-investing at the tail end of life and under-investing in conception to age three; still unaware that the home could be a center of health and the care team could have (should have) a 24/7 health professional presence in it?
What if our mentors are able to “voice” and “model” professionalism, and even appear to be “practicing” professionalism, but the system itself makes it impossible for them and for their students to “realize” true professionalism?
The role of ‘professionalism’ in training of physicians and in the delivery of care has been heralded by major scientific bodies including the AAMC, Institute of Medicine, the ACGME and the ABMS. Their listing of desirable attributes in health care professionals is helpful. However, what Fitzhugh Mullan understood was that—absent the context of rapid environmental change, the modeling of new approaches to care that are emerging from both the consumer and provider side, and the integration of the latest social science concepts which impact human planning, development and potential—physicians will predictably under-perform in the modern world.
What does Advanced Professionalism require? “Who am I becoming?” must be accompanied by “What am I building, where, how and for whom?”
Mike Magee MD is a Medical Historian and Health Economist at the Presidents College at the University of Hartford.