Teaching about professionalism

Whatever the challenges, and there are many, professional development must become a part of the core undergraduate medical curriculum, and not a parallel or ‘bolt-on’ curricular strand. This is one of the messages in a thought-provoking paper by Jill Gordon of Sydney University in this issue.1 She argues the case for an increased emphasis on personal and professional development (PPD) in the training of doctors, offers an evidence-based framework for a PPD curriculum, and highlights some of the problems and their solutions. She also looks at the thorny issue of selection of students. The paper is an important contribution to a growing literature on the subject of teaching about professionalism, this includes many published in this journal. Historically, the basic tenets of professionalism in medicine (that it is a vocation; has a distinctive knowledge base; determines its own standards and self regulates; has a special relationship with those it serves; and is guided by particular ethical principles,2) have been implicit in both the practice and the education of doctors. It was assumed that most of the correct attributes were already present in those selected for medical school, and that the rest would be picked up from their teachers by ‘osmosis’. Once qualified, it was taken for granted that the majority of doctors would continue to practise according to these tenets for the rest of their professional lives. However, as Gordon points out,1 the historical approach to selection, based on high grades in science subjects, whilst predictive of academic achievement, does not necessarily guarantee the development of appropriate professional attributes (altruism, humanism, respect for others, integrity, self-awareness, are some of the qualities frequently referred to,1, 3,4). Furthermore, the ubiquitous osmotic process, mediated largely through role modelling and the ‘hidden curriculum’, is notoriously fickle, and may even have a deleterious effect, reinforcing negative and maladaptive behaviours and fostering cynicism. Over the past decade, however, as professionalism itself and the nature of medicine's contract with society have been revisited3 so too teaching about PPD has assumed a major place on the medical educator's agenda. Publication of guidelines for both education and practice, such as the General Medical Council's Tomorrow's Doctors5 and Good Medical Practice6 obviously played a major part in leading the way. Notwithstanding this, one should not forget the efforts of the (usually) small, but long-suffering band of educators in probably every medical school, struggling over the years to introduce relevant teaching and learning in areas such as communication, ethics, and humanism. This was often in the face of considerable ignorance, lack of vision or obstruction by deans, fellow academics and curriculum committees (as Gordon points out, however, most of the potential objections can be robustly challenged), and their achievements in laying the foundations for PPD curricula should be given due credit. Two years into the new millennium, and PPD curricula appear to have been implemented in most medical schools.7 Teaching about professionalism has also become an important theme at medical education conferences, both national and international. For example, at a national meeting on the subject held in Durham in the UK in September 2001, the majority of British medical and dental schools were represented. Similarly, the 10th Ottawa conference in Ottawa, and the Association for Medical Education in Europe conference in Lisbon in 2002, both had major sessions dedicated to professionalism. However, educators face several major challenges in taking this agenda forward. Firstly, although broad aims and principles have been defined,3, 7,8 there is a need, highlighted by Howe9 to develop theory further to underpin practice, teaching and research. Secondly, in this era of evidence, it is important to evaluate educational developments thoroughly – do the new approaches to student selection and/or the different content and methods of teaching about professionalism make a difference? Without the evidence it will be hard to justify the more resource-intensive methods that such teaching and learning inevitably requires, increasingly in this era of shrinking resource and increased student numbers. Last, and by no means least, there is the challenge of assessment. A recent review concluded that although the current array of assessment instruments is rich and holds great potential, their measurement properties must be strengthened considerably, and there is a continuing need to rigorously explore qualitative methods, and to consolidate the quantitative.4 An important issue is the fact that personal and professional development is by its very nature a process, rather than an end-point, which poses a significant challenge regarding both formative and summative approaches.4, 10. Teaching about professionalism is an idea whose time has come, and given public demands for greater accountability, partnership and better communication, is unlikely to go away. However, medicine cannot change things on its own. There is a need for the contract between society and the profession, what Smith called the ‘bogus contract’ because of its unrealistic and unattainable expectations, to be redefined such that the limitations of medicine are much more openly acknowledged by both parties. This, he argued, may lead to ‘a much more honest, adult and comfortable relationship’.11.

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