Book Review

Measuring Medical Professionalism

N Engl J Med 2006; 355:219-221July 13, 2006

Article

Measuring Medical Professionalism
Edited by David Thomas Stern. 311 pp. New York, Oxford University Press, 2006. $49.50. ISBN: 0-19-517226-4

This book on the multifaceted problem of measuring medical professionalism is interesting and valuable. It has something for any reader seeking to understand whether, why, or how professionalism in medicine might be evaluated.

The editor, David Thomas Stern, asks whether the concept of “professionalism” is like the concept of “obscenity” — something hard to define but recognizable when observed. Stern, along with Louise Arnold, rejects this glib definition in a very thoughtful essay the two contributed to this book identifying the central qualities of professionalism as excellence, humanism, accountability, and altruism. Predictably, the many other contributors to the book perceive professionalism and its assessment or measurement in many different ways.

Jon Veloski and Mohammadreza Hojat, in their chapter entitled “Measuring Specific Elements of Professionalism: Empathy, Teamwork, and Lifelong Learning,” apply systems theory to the assessment of professionalism. On the basis of the assumption that empathy, teamwork, and a commitment to lifelong learning are important components of professionalism, they have developed questionnaires to assess each of these qualities. These assessments may be thought of as global, quantitative assessments of specific properties that define professionalism. The authors suggest that the evaluations are important tools for testing hypotheses concerning the admission of students to medical school, studying changes in the attitudes of students as they progress from preclinical to clinical studies, predicting performance in the training of house staff, and evaluating changes in medical school curricula.

Maxine Papadakis and Helen Loeser, in their chapter entitled “Using Critical Incident Reports and Longitudinal Observations to Assess Professionalism,” address the measurement of professionalism not as a continuous quantitative function but as a binary function — pass or fail — akin to a driving test. Critical incident reports, which are faculty reports of students' behavior that is deemed to be unprofessional, are the initial step in identifying outliers — students or physicians in training who may have special needs, are responding poorly to the stresses of the program or other parts of their lives, and may require counseling or remediation. Papadakis and Loeser describe their experience of assessing professionalism through a physician evaluation system at the University of California, San Francisco (UCSF), and they point to the need for faculty to understand and actively participate in the on-site evaluation of student and house staff behaviors. They acknowledge that “single events do not necessarily define professionalism.” They also provide data on the number and types of unprofessional behaviors identified since the inception of the system at UCSF in 1995, describe the distribution of critical incidents among the clinical services, and outline the process and legal issues associated with remediation. Shiphra Ginsberg and Lorelei Lingard, in their chapter entitled “Using Reflection and Rhetoric to Understand Professional Behaviors,” suggest that critical incidents, serving as topics for reflective essays or small group discussions, have the potential for stimulating students to examine their own reasoning and behavior.

Debra Klamen and Reed Williams, in a chapter entitled “Using Standardized Clinical Encounters to Assess Physician Communication,” address the important issue of standardization in evaluation and the increasing dependence on “standardized patients,” who they define succinctly as “nonphysicians carefully trained to perform in multiple roles of patient, teacher, and evaluator while realistically replicating a patient encounter.” They present data on the reliability and validity of standardized patient examinations, whether evaluated by the “standardized” patient or a third-party observer.

Although this mode of evaluation has the advantages of standardization and the generation of reproducible data, many medical educators and clinical teachers (this reviewer among them) question the technique. When students know they are examining a standardized patient, is their behavior representative of their usual behavior? Students have a remarkable ability to show the side of themselves that they perceive as desirable; why else would virtually every applicant for internship appear in a trim, ultraconservative dark suit? Most of clinical medicine is taught by careful history taking, examination of real patients, and discussions of differential diagnosis, pathophysiology, or disease management. Students' behavior and their ability to elicit relevant information and demonstrate critical assessment of data are easily observed during such clinical teaching sessions. In my view, the advantages of assessment during contact with real patients — a situation that is not a one-time experience, is not perceived as a “test,” and fits the medical model — outweigh the lack of “standardization.”

Even though readers may quarrel with some of the views expressed in this book, the editor should be praised for bringing together this talented group of medical educators. In his acknowledgments, Stern writes, “These authors are more than expert researchers or physicians, they demonstrate the highest degree of collegiality, intellectual integrity, compassion, and teamwork — they practice what they preach.” This book suggests that they also preach what they practice.

Jerome Lowenstein, M.D.
New York University School of Medicine, New York, NY 10016