Relevance of the rationalist-intuitionist debate for ethics and professionalism in medical education

Despite widespread pedagogical efforts to modify discrete behaviors in developing physicians, the professionalism movement has generally shied away from essential questions such as what virtues characterize the good physician, and how are those virtues formed? Although there is widespread adoption of medical ethics curricula, there is still no consensus about the primary goals of ethics education. Two prevailing perspectives dominate the literature, constituting what is sometimes referred to as the "virtue/skill dichotomy". The first perspective argues that teaching ethics is a means of providing physicians with a skill set for analyzing and resolving ethical dilemmas. The second perspective suggests that teaching ethics is a means of creating virtuous physicians. The authors argue that this debate about medical ethics education mirrors the Rationalist-Intuitionist debate in contemporary moral psychology. In the following essay, the authors sketch the relevance of the Rationalist-Intuitionist debate to medical ethics and professionalism. They then outline a moral intuitionist model of virtuous caring that derives from but also extends the "social intuitionist model" of moral action and virtue. This moral intuitionist model suggests several practical implications specifically for medical character education but also for health science education in general. This approach proposes that character development is best accomplished by tuning-up (activating) moral intuitions, amplifying (intensifying) moral emotions related to intuitions, and strengthening (expanding) intuition-expressive, emotion-related moral virtues, more than by "learning" explicit ethical rules or principles.

Responding to moderate breaches in professionalism: an intervention for medical students

Much has been written about how we understand, teach and evaluate professionalism in medical training. Less often described are explicit responses to mild or moderate professionalism concerns in medical students. To address this need, Baylor College of Medicine created a mechanism to assess professionalism competency for medical students and policies to address breaches in professional behavior. This article describes the development of an intervention using a guided reflection model, student responses to the intervention, and how the program evolved into a credible resource for deans and other educational leaders.

Organizational philosophy as a new perspective on understanding the learning of professionalism

OBJECTIVE

To define the concept of "organizational philosophy" through identification of elements within undergraduate pharmacy curricula in the United Kingdom that contribute to students' learning of professionalism.

METHODS

A qualitative study using curriculum mapping was conducted to identify "intended," "taught," and "received" curriculum in 3 schools of pharmacy. The study involved review of course materials, interviews with teaching staff members, focus groups with final year students, and observation of classes.

RESULTS

"Organizational philosophy" (totality of all contributors) played a vital part in students' professionalism learning. Key contributions were not restricted to the "taught" curriculum but extended to the wider academic environment. Setting of high standards appeared important; role models had particular significance. Importance of professionalism learning being grounded and longitudinal throughout the curriculum was highlighted. An "integrated" organizational philosophy appeared to be achieved where maximum overlap occurred between "intended," "taught," and "received" curricula.

CONCLUSIONS

Professionalism learning goes beyond the "taught" curriculum in pharmacy schools. The concept of "organizational philosophy" acknowledges the importance of integration between "intended," "taught," and "received" curriculum in the context of overall organization.

Reconciling the professional and student identities of clinical psychology trainees

The study explored the ways in which qualified and trainee clinical psychologists perceived professional behaviour, as illustrated in a series of short vignettes, in student and clinical practice contexts. Comparisons were made to identify the extent to which ideas of professionalism differed across different learning contexts and between qualified and unqualified staff, with the aim of adding to the literature on which factors influence the development of professional identity in health professionals. An online questionnaire depicting a range of potentially unprofessional behaviours was completed by 265 clinical psychology trainees and 106 qualified clinical psychologists. The data were analysed using a general linear model with simultaneous entry in which rater (trainee vs qualified clinical psychologist), setting (student vs placement) and their interaction predicted acceptability ratings. We found that, in general, trainees and qualified staff agreed on those behaviours that were potentially unprofessional, although where significant differences were found, these were due to trainees rating the same behaviours as more professionally acceptable than qualified clinical psychologists. Despite trainees identifying a range of behaviours as professionally unacceptable, some percentage reported having engaged in a similar behaviour in the past. Irrespective of the status of the rater, the same behaviours tended to be viewed as more professionally unacceptable when in a placement (clinical) setting than in a student (university) setting. Generally, no support was found for a rater by setting interaction. The study suggests that trainee clinical psychologists are generally successful at identifying professional norms, although they do not always act in accordance with these. Conflicting student and professional norms may result in trainees viewing some potentially unprofessional behaviour as less severe than qualified staff. Health professional educators should be aware of this fact and take steps to shape trainee norms to be consistent with that of the professional group.

Medical students on the stage: an experimental performative method for the development of relational skills

BACKGROUND

Development of therapeutic relational skills is a relatively neglected area of medical education. Conventional teaching techniques are mostly unsuitable for the realization of experience-based learning.

AIMS

To develop a training method which enables lived self-experiences of the therapeutic relationship in class. To help students understand that illness and the doctor-patient relationship are integrated in the network of life histories and other relationships.

METHODS

Our Integrated Performative Action Method is based on the elaboration of a short story of an illness in a student group. Through the 5 phases of the process, students write their own version of the story, build up characters, scenarios and enact the play. We have tested the method with 6 groups of students (n = 70) in a 10-week course. Video-recordings and minutes of sessions were analysed by two independent observers.

RESULTS

Through elaborating the characters and playing the roles, students could speak about their own problems and act out feelings in the name of the characters. All groups had strong involvement throughout the process.

CONCLUSIONS

The method helps to experience the ways in which therapeutic relationships and professional identities are constructed, reflected upon and communicated in a group of medical students.

Building character: a model for reflective practice

In 1950, Harrison and colleagues proposed that the physician's ultimate and sufficient destiny should be to "build an enduring edifice of character." Recent work in philosophy underscores the importance of character ethics (virtue ethics) as a complement to ethical systems based on duty (deontology) or results (consequentialism). Recent work in psychology suggests that virtues and character strengths can, to at least some extent, be analyzed and taught. Building character might be enhanced by promoting among students, residents, and faculty a four-step method of reflective practice that includes (1) the details of a situation, (2) the relevant virtues, (3) the relevant principles, values, and ethical frameworks, and (4) the range of acceptable courses of action. Exercises using such a model bring together the major goals of ethics education in U.S. medical schools--teaching the set of skills needed for resolving ethical dilemmas and promoting virtue and professionalism among physicians.

Authentic community as an educational strategy for advancing professionalism: a national evaluation of the Healer's Art course

BACKGROUND

Efforts to promote medical professionalism often focus on cognitive and technical competencies, rather than professional identity, commitment, and values. The Healer's Art elective is designed to create a genuine community of inquiry into these foundational elements of professionalism.

OBJECTIVE

Evaluations were obtained to characterize course impact and to understand students' conceptions of professionalism.

DESIGN

Qualitative analysis of narrative course evaluation responses.

PARTICIPANTS

Healer's Art students from U.S. and Canadian medical schools.

APPROACH

Analysis of common themes identified in response to questions about course learning, insights, and utility.

RESULTS

In 2003-2004, 25 schools offered the course. Evaluations were obtained from 467 of 582 students (80.2%) from 22 schools participating in the study. From a question about what students learned about the practice of medicine from the Healer's Art, the most common themes were "definition of professionalism in medicine" and "legitimizing humanism in medicine." The most common themes produced by a question about the most valuable insights gained in the course were "relationship between physicians and patients" and "creating authentic community." The most common themes in response to a question about course utility were "creating authentic community" and "filling a curricular gap."

CONCLUSIONS

In legitimizing humanistic elements of professionalism and creating a safe community, the Healer's Art enabled students to uncover the underlying values and meaning of their work--an opportunity not typically present in required curricula. Attempts to teach professionalism should address issues of emotional safety and authentic community as prerequisites to learning and professional affiliation.

See one, do one, teach one: developing professionalism across the generations

Individuals develop their professional values and identity as they progress through the hierarchical career stages of medicine. At the same time, the collective values of the profession evolve with changes in the wider society. This leads to recurring small but significant generation gaps in professional values. For the past half century, this gap has centered on the concept of altruism and quality of life. In order for professionalism to develop at the individual level as well as for the community of physicians, the generational differences must be bridged and negotiations for change must build on common ground. This requires a long-term developmental approach including teaching strategies which are career stage appropriate and adapt to the different learning styles of the younger generation.

Humanities in full retreat

BACKGROUND

Professionalism is a crucial component that sustains the status and practice of clinical medicine.

DESCRIPTION

At the Penn State College of Medicine, Milton S. Hershey Medical Center, the Department of Humanities has developed a cross-disciplinary, annual retreat for resident leaders to help them reflect on the nature of professionalism and on what it means to be a role model. The retreat also provides resident leaders the opportunity to discuss common challenges such as dealing with the stress of residency, giving bad news, working with "difficult" patients, dealing with one's mistakes, and finding meaning and purpose in medicine.

EVALUATION

The retreat is evaluated by resident participants using a Likert scale and open-ended responses and has received consistently excellent evaluations.

CONCLUSION

We have developed an effective, consistently successful retreat for providing residents across the spectrum of medical training with an enriching humanities experience. Such a retreat could be easily exported to other institutions to promote professionalism during residency.

Ethical conflicts between residents and attending physicians

Conflicts between residents and attending physicians over ethical issues often occur and residents must attempt to navigate these perilous waters. A brief description of a conflict concerning informed consent and professional role expectations in a neonatal intensive care unit is presented. The discussion then explores contextual features that often shape such ethical conflicts and presents ways of understanding ethical conflicts that occur in the course of medical training. Constructive approaches for residents to engage in conflict resolution are offered.