Book Review

Educating for Professionalism: Creating a Culture of Humanism in Medical Education

N Engl J Med 2001; 345:227-228July 19, 2001

Article

Educating for Professionalism: Creating a Culture of Humanism in Medical Education
Edited by Delese Wear and Janet Bickel. 215 pp. Iowa City, University of Iowa Press, 2000. $42.95. ISBN: 0-87745-741-7

Educating for Professionalism: Creating a Culture of Humanism in Medical Education presents a candid and sometimes painful look at the culture of undergraduate medical education. “We are learning when you least expect it,” says an anonymous medical student in the book's epigraph; this may be an alarming notion, given the current state of health care in America. The 13 essays in the book, which were written and edited by a diverse group of respected medical educators, address this notion and offer nothing short of hope for the future.

“How does . . . a commitment to the well-being of others either wither or turn into something barely recognizable?” asks one essayist. The answers, which address all stages of the professional development of physicians, are familiar and are outlined in the first part of the book.

Premedical students develop a one-dimensional, competitive focus that best serves only the admission committees at medical schools. The curriculum they go on to study is strikingly disconnected from the mission statements of the schools; rarely do course objectives include the inculcation of altruism, advocacy, and other forms of moral development. Moreover, although schools provide a formal education and assess performance, it is the unseen transmission of the dominant culture rather than the formal program that may have the greatest impact on the professional development of students. It is within this “hidden curriculum” that students, even as they are learning to care for patients, learn from the faculty the uses of authority, power, and knowledge. But if the members of the faculty are inadequately supported and generally overwhelmed, thus leading too many students to draw negative conclusions, a dangerous downward spiral will start and “academic medicine will have eaten its seed corn.” A powerful antidote, the mentor–protégé relationship, is seldom a celebrated part of medical-school culture.

The absorbing essays in the first third of the book are true to its theme of self-reflection as an integral aspect of professional development. They are devoted to understanding the experience of undergraduate medical education, and they challenge the reader to consider the effect of the guiding principles of each institution on the moral development of its students, the crucial role of the hidden curriculum, and the restrictiveness of “professional roles” for those striving for integrity and authenticity. The section ends with a discussion of the conflict between our willful commitment to traditional values of doctoring and our unconscious commitment to traits — fostered by contemporary medical education — that make it difficult to be a caring physician.

The second part of the book offers cause for hope. With the assumption that mentoring relationships, student-initiated activities, and learning to serve stimulate professional growth, this section chronicles the efforts of students, faculty, and their communities in shaping medical education. Wear and Bickel have compiled myriad examples of challenges and opportunities at this intersection of professional development and social consciousness.

In one example, a professor of philosophy, a clergyman, and a medical ethicist have collaborated to write one of the most vital chapters, entitled “Moral Growth, Spirituality, and Activism: The Humanities in Medical Education.” Andre and colleagues, who define spirituality as “the search for what ultimately gives meaning to life,” which “grounds the deepest thinking about the person — the physician — that one wants to become,” describe the spirituality course at their institution. The authors observe, “Much of the suffering that accompanies serious disease is produced by, and can only be alleviated through, the personal meaning that one attaches to the experience” and note that the “busyness” of daily life can keep physicians from making the critical distinction between the seemingly urgent and the truly important. This essay describes a beautiful and necessary — but often lacking — aspect of the training of the fully developed “professional.”

Maintaining that the mentor–protégé relationship is central to the professional development of students, another chapter offers two new ways of framing the alliance. The writers, all educators and psychiatrists, present schematic representations of professional and personal development and argue strongly that a successful relationship must incorporate both.

The last chapters expand on the central theme that through student-directed community experiences, “the values of service and a fiduciary orientation are internalized most successfully.” These chapters highlight community-based programs that provide students with firsthand experience in attending to the health needs of various populations.

Those directly involved in undergraduate medical education will find this book inspiring. However, it should be required reading for all who believe that irreversible damage would be done to the institution of American medicine if competent, patient-centered physicians were produced only serendipitously. From an optimistic perspective, the transformation outlined in this book could have a ripple effect on its implementers and teachers and ultimately on the wider culture of medicine. But it is hard to imagine such a profound paradigm shift occurring in less than a generation. What of the interim?

Bickel ends with an answer, perhaps the raison d'être of the book:

These perilous times require that each — from student to dean — be ever developing as professionals, as communicators, as leaders. Communities expect leadership from physicians. And no wonder. No group is better equipped to champion improvements in the health care system. While competition and restrictions may be mounting, physicians are the ones with the greatest access to knowledge of the human body, to medical technology and resources, and to the respect of those they serve. If courageous and compassionate, each physician has enormous potential for positive impact. This book offers a wealth of ideas on better realizing these potentials. Opportunities do abound.

James L. Meisel, M.D.
Harvard Medical School, Boston, MA 02115
jmeisel@partners.org