Are We
Educating a Medical
Professional Who Cares?
Robert G. Petersdorf, MD, Kathleen Turner, MPA \s=b\ We examined four domains in which physicians must demonstrate their capacity for caring. These include the knowledge base that forms the foundation for the practice of medicine, the personal characteristics and attributes that a physician brings to the profession, the individual patients for whom the physician accepts responsibility, and the society in which the physician lives. We conclude that the system of medical education does produce caring physicians. The profession's history of self-evaluation and criticism should not obscure medicine's real success in meeting its responsibility to care as well as to cure.
(AJDC. 1992;146:1338-1341)
education of medical professionals must be con¬ cerned with caring as well as curing. In this era of high-technological medicine, the American system of med¬ ical education has not always done the best possible job in
The
preparing caring physicians. Probably the first question to consider is what young medical professionals should care about. There are four important domains about which physicians should care. They include the following: (1) the knowledge base that forms the foundation for the practice of medicine, (2) the personal characteristics and attributes that a physician brings to the profession, (3) the individual patients for whom the physician accepts responsibility, and (4) the so¬ ciety in which the physician lives. KNOWLEDGE BASE knowledge base about which a physician should care can be narrowly defined as the curricular content of medical school and residency training. A more liberal view is that young physicians should care that their total academic preparation educates them as well-rounded cit¬ izens with a broad perspective on both their society and their profession. While our medical students and residents care about the knowledge base that will support their practice of medicine, it is less certain that they are convinced of the professional value of a broadly based ed¬ ucation. If they were, 70% of our medical school applicants The
1992. From the Association of American Medical Colleges, Washington, DC. Adapted from the Commencement Address, Tulane University, New Orleans, La, June 6, 1992. Reprint requests to the Association of American Medical Colleges, 2450 N St NW, Washington, DC (Dr Petersdorf).
Accepted for publication August 13,
would not be majoring in science at the baccalaureate level. In general, graduates of US medical schools receive an excellent education. The system of peer review and eval¬ uation of medical education as exercised by the Liaison Committee on Medical Education (LCME) ensures a rela¬ tively uniform standard of quality. The standards promul¬ gated and monitored by the LCME reflect a community consensus about the core curriculum and subjects that are essential to the awarding of the medical degree. The fact that 96% of medical students are graduated speaks elo¬ quently both to the quality of the young men and women attracted to medicine as a career and to the care that goes into their education. American medical education is particularly excellent in the preparation of students in the basic biomedicai sciences and in the clerkships that form the core experiences of clinical education. Our system of medical education has always recognized the importance of physicians having a firm grounding in basic science, followed by a period of supervised, hands-on instruction. Even the most cursory examination of American medical education reveals that medical schools produce young physicians who are well educated in medicine. However, it is much more difficult to respond yes to the question whether our students are broadly educated. All too often a career in medicine is launched in the rigid premedical educational environment that prevails in colleges and universities. Students become study machines, char¬ acterized as hypercompetitive and narrow-minded at best, and greedy and dishonest at worst. They are thought to be interested only in courses they believe will ensure their admission to medical school. Students in college should be broadening their educational background, experimenting in the study of a number of disciplines, and setting their minds to new intellectual horizons. Instead, we hear too often of students who will not consider an intellectually challenging course for fear of getting a poor grade and hurting their chances of admission to medical school. Faculties at medical schools should also be thinking about the signals they send to their medical students. When presenting information in the basic sciences, do they correlate it with the care of future patients? Or do they say, "Learn this; it will be on the National Boards"? Do exam¬ inations reward fact grubbing, or do they encourage inte¬ grative thinking? Our students are bright and competitive, and we must be attentive to the underlying messages transmitted to them about the knowledge base. We want our students to care about the knowledge presented them
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because of its relevance to their future careers, not because of a single examination or their relative class standing. To accomplish this, we must be prepared to make some changes in the way medical education is structured. Med¬ icine has been extraordinarily fortunate because we have consistently been able to attract the best and brightest of our young people—by definition, people who can think. Regrettably, however, medical curricula have done little to teach students how to think. Our failure has been that we have emphasized rote learning and have relied too heavily on didactic presentations as the preferred pedagogical method. There has been an elemental gap between the ba¬ sic science years and the clinical years, and we have not been very successful in integrating those two stages of medical education. We are beginning to see change. The shortcomings of the didactic lecture as a teaching tool are a matter of record, especially in preparing for a profession whose practitio¬ ners must develop the habit of lifelong learning to main¬ tain professional competence. Although our faculties seem able to support this reform in principle, when it comes to hard decisions about what gets dropped from the curric¬ ulum, consensus evaporates. The Association of American Medical Colleges' (AAMC) curriculum directories indicate that from 1983 to 1989 the mean number of scheduled hours for required first-year courses decreased from 933.6 hours to 854.5 hours. Mean lecture hours declined from 465.3 to 440.8.u These changes are not monumental, but at least they signal a move in the right direction. We know our medical students care about their level of knowledge. A walk through any student lounge the day before an examination will confirm that. What is more im¬ portant is that they understand the importance of this cog¬ nitive base in the context of a longer professional career. A medical professional must be a lifelong learner. Physicians must care about their fund of knowledge, because they cannot be competent in the practice of medicine if this ba¬ sic professional tool becomes obsolete. The message we convey to students must be that the knowledge they acquire in medical school is not a sterile exercise in mem¬ orization but that it relates to their future patients. It is a living body that requires constant attention and review. How successful are we in relaying this to medical students? Perhaps we should be content with the observa¬ tion that they do care about the knowledge base, that they recognize its importance, and that they do well in acquir¬ ing that knowledge base and accomplishing our curricular objectives. However, the profession would be improved if all physicians were more broadly educated and able to place their professional knowledge within a larger intel¬ lectual context.
build their professional lives. With the privileges of being a physician go certain responsibilities, and failure to meet those responsibilities can exact a heavy price from the so¬ ciety on whose goodwill our professional privileges rest. Let us mention two instances in which the loss of integrity has done irreparable harm to our profession and bodes ill for its future. A decade ago the scientific world was stunned by the revelation that nearly the entire corpus of scientific publi¬ cation by a medical school faculty member was fraudulent. This was no honest disagreement on the interpretation of data or an accidental laboratory error that obfuscated the experimental results. It was a deliberate attempt to achieve personal advance by betraying the principles of scientific inquiry. That infamous case has been followed by others, perhaps less notorious, although no less nefarious. In re¬ sponse, a shaken scientific community has initiated a reexamination of professional peer review, scientific pub¬ lishing, and policies for investigating allegations of mis¬ conduct. However, the damage is done. The special place biomedicai research has held in the public's eye has been irreparably sullied by the revelation that some in the pro¬ fession have placed their personal ambitions ahead of their
PERSONAL CHARACTERISTICS AND ATTRIBUTES A distinguishing feature of a profession such as medi¬ cine is that there is a code of ethical behavior that, if not unique to the medical profession, is at least required of those who practice it. The Hippocratic oath represents the core of ethics for the physician, who is expected to be not
physicians?
only a knowledgeable
and well-educated individual but also one of demonstrated honesty and integrity. The ques¬ tion whether our students care about the personal charac¬ teristics and attributes of a physician is more difficult to answer than the question whether they care about their knowledge base. Integrity must be the cornerstone on which physicians
integrity.
Some individuals who aspire to careers in medicine ap¬ pear willing to go to any lengths to achieve their goals. For several recent examination cycles the examination that foreign medical graduates need to pass to qualify for house staff training in this country has been pilfered and is for sale "on the street" at $5000 per examination, and there is good evidence that some candidates achieved scores that defied credibility and that could not be sustained on sub¬ sequent examinations. The epidemic of thievery has ex¬ panded to the AAMC's Medical College Admission Test (MCAT) and the National Boards. At its first administra¬ tion in April 1991, the new version of the MCAT was pur¬ loined from a supposedly safe test center. Of course, the examination has been rewritten, but where is the integrity of some individuals who are willing to cheat a profession before they even enter it?3 An interesting discussion surfaced recently in response to an article published in the Journal of the American Med¬ ical Association4 that reported that only 54% of residents discussed their most significant mistake with their attend¬ ing physician. The article also indicated that those who ac¬ cepted responsibility for mistakes and discussed them
likely to report constructive changes in practice. It leads one to wonder about the motivation of these young physicians during their residency. Are they more inter¬ ested in getting through the period without embarrass¬ ment, or do they see this period as part of the medical ed¬ ucation process that will prepare them to be better
were more
It is facile to talk about the breakdown in moral values our society, but even if this is the case, it is not possible for the medical profession to accept a lowered standard of ethical conduct. If, indeed, society, the family, or the edu¬ cational system is not fostering ethical values in its mem¬ bers, then the medical profession, through its educational system and the socialization of new members of the pro¬ fession, must attempt to fill the void. We must worry about whether medical students care about personal attributes and characteristics that are essential to the profession of medicine. Medical education in recent years has attempted to introduce more teaching in
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ethical issues in the curriculum. However, most of the work on medical ethics concentrates on patient care issues, and devotes little time to common medical student dilemmas, the study of which might improve medical stu¬ dents' moral reasoning. For example, a 1990 report5 revealed that fewer than half of medical schools have a student honor code. Studies of medical students show substantial disagreement about whether particular behaviors are unethical. In one study, only 38% believed "signing an attendance sheet for a friend" was wrong; 31% did not believe that copying a laboratory report from a friend was cheating.6 Especially troublesome for medical students and residents is the di¬ lemma they face when they observe unethical behavior in a peer. Our goal should be to encourage students to accept responsibility for the ethical climate, including responsi¬ bility for each other as professional colleagues. Faculty and institutional leadership at academic medical centers should consider several questions in their efforts to improve the moral and ethical environment: Do medical students witness and participate in be¬ haviors in conflict with professional ethics, such as differ¬ ent treatment for patients with private insurance, manip¬ ulation of diagnosis related groups for reimbursement purposes, or inappropriate relationships with pharmaceu¬ tical companies? Are examinations and evaluation procedures fair, thereby reducing peer pressure and minimizing the temp¬ tation to cheat? Are the ethical standards expected of students and residents clearly articulated and understood by them? Are there appropriate mechanisms for them to seek advice and report violations of these standards? Is the medical center supportive of cultural differ¬ ences, providing an atmosphere that is free of racism and sexism? Our medical students and residents can be educated to care about the personal attributes and characteristics of ethical physicians only if we as medical educators are pre¬ pared to provide a moral example for them. In his chair¬ man's address to the AAMC, Bennett7 made this point by quoting Sir William Osier: "This higher education so much needed today is not given in the school, is not to be bought in the market place, but it has to be wrought out in each one of us for himself; it is the silent influence of character on character. ..." on
course
•
•
•
•
CARING FOR PATIENTS Medicine is often described as having two separate components, ie, the science of medicine and the art of medicine. I have touched already on the science of medi¬ cine. Yet the physician's relationship with patients must also consider the art of medicine. What exactly is the art of medicine? There have been many definitions. Voltaire8 be¬ lieved it occurred when a physician "... successfully amuses his patients while Nature effects a cure." L. Holly Smith,9 former chairperson of medicine at the University of California, San Francisco, has another definition: "In the art of medicine the physician must be the advocate of the patient as well as the adversary of disease." To be an advocate for patients the physician must understand patients and know how to communicate with them. In recent years medicine has been criticized for be¬ ing too scientific and insufficiently humanistic. Some seem
to believe that science and
humanity are dichotomous and mutually exclusive, that technology and compassion can¬ not be found within a single physician. As medical profes¬
sionals we must refute this belief. In 1985 the American Board of Internal Medicine ap¬ proved a guide to awareness and evaluation of humanis¬ tic qualities in the internist.10 This action is important in two respects. First, it recognized that the knowledge base for medicine is not exclusively scientific. Second, it ex¬ pressed a belief that humanism in medicine can be actively
taught.
Medicine has apparently had no trouble in teaching its acolytes to be inhuman. New medical students are almost uniformly idealistic and motivated to serve their fellow human beings. Yet somewhere in the medical education process a large number of them seem to become hardened and cynical, skeptical about the value of the art of medi¬ cine. Perhaps this occurs because of the overwhelming emphasis medical schools place on biomedicai science and because of the stressful physical demands of the residency
years. Students
of this, and they fear the loss of see that they as the natural outgrowth of ad¬ compassion vancement in medical education. Each year the AAMC polls graduating medical school seniors.11 The question¬ naire is extensive, collecting information on their back¬ ground, their training and career plans, how their medical education was financed, and their experiences in medical school. Among the questions is one that asks students to rate the time they spent in various subjects during medical school as excessive, appropriate, or inadequate. The graduates overwhelmingly rank as excessive the time devoted to ba¬ sic medical sciences information. On the other hand, among the topics viewed by those same graduates as re¬ ceiving inadequate attention during undergraduate med¬ ical education are management of the patient's socioeco¬ nomic, educational, and emotional problems; effective patient education; therapeutic management; the role of medicine in the community; independent learning and self-evaluation skills; and patient interviewing skills. It seems clear from these data that medical students do care about the art of medicine. Furthermore, they recognize that the medical schools seem unable to help prepare them in this important respect. Coulehan12 has noted, "Curricu¬ lum to teach the clinical art suffers from expansion of the disease-oriented curriculum, but also its own conceptual weakness. Our art, though hoary with age, has been almost entirely grounded in tacit knowledge. It has not been well formulated into intelligible and systematic components." The biopsychosocial approach to medicine emphasizes the relevance of both the social and natural sciences to medicine. We do a disservice to our students when we ig¬ nore or downplay one of these elements. Students want very much to be caring physicians, but we do not do much to help them. In Dear Doctor Odegaard13 wrote, "... the process of education for the physician's role has not pro¬ vided sufficient instruction on the human relationship be¬ tween the patient and the physician." A recently released movie expands on this theme. The film depicts an arrogant, omniscient physician who learns to be humanistic and caring only after he himself becomes a patient with a lifethreatening illness. Surely, as a teaching tool this example may be too extreme, but its shock value is indisputable. Somehow we must do better in responding to students' are aware
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desire to care,
patients.
emotionally as well as physically, for their
RESPONSE TO SOCIETY'S CONCERNS Medicine is frequently accused of being uncaring about society's needs. For the most part, this characterization is unfair. Much of the blame for societal ills, such as the lack of access to the health care system for 35 million Ameri¬ cans, spotty care for the indigent, high neonatal mortality, and high health care costs, has been laid at the door of medicine. Medicine is not to blame for such social blights as substance abuse, the crime that follows in its wake, homelessness, poverty, urban decay, rural deprivation, and illiteracy. These are matters in which the body politic has failed because it has systematically starved the social infrastructure so laboriously constructed in the 1950s, 1960s, and 1970s. It has also failed to impose the discipline required to solve some of these problems. Rhetoric will not do it; sensible and fair taxes that we, the people, are will¬ ing to pay might. An example of where medicine has done its part has been in the dreaded scourge of the 1980s, the acquired im¬ munodeficiency syndrome. In just a decade scientists have identified the virus, elucidated how it works, and found ways to contain it. A cure, or at least better containment and prevention, is a feasible agenda for the 1990s. With the exception of some fear-engendered failures to care for pa¬ tients with the acquired immunodeficiency syndrome, the medical profession has played its role well, and, for the most
part,
our
A second
for the failure to produce primary care be that physicians may primary care has not been a valued activity of academic medical centers. When asked why they selected a particular specialty, graduating seniors frequently cite the influence of a positive educational ex¬ perience or the personal example of a role model. We must wonder just how much exposure to primary care medicine and its practitioners our students receive in the tertiary care, technologically sophisticated modern academic med¬ ical center. Physicians do care about society's needs, particularly the curing of disease and the restoration of health. While the profession has been unable to address the primary care is¬ sue, individual physicians cannot be blamed for this fail¬ ure. It is the leadership of academe and the medical care system that have failed to instill a sense of value and importance for that much-needed component of our reason
profession.
COMMENT Are we educating medical professionals who care about themselves as physicians, about their patients, and about society? For the most part, we are, although there is always room for improvement. Medicine has a long history of self-examination and criticism directed toward improving the profession. We should not allow this tendency and the observations it illuminates to obscure our very real successes.
hospitals, particularly teaching hospitals,
have met the crisis responsibly and humanely. While long-term care for these desperately ill patients still leaves a lot to be desired, it is improving. That is not to say that we can look at medicine's record with complete satisfaction. We still have a long way to go to come up to societal expectations. An example is the publicly perceived and often articulated need to train more primary care physicians. With some notable exceptions we are not doing it. In 1990 only 26.3% of our medical school graduates indicated that they intended to pursue a career in general practice, family medicine, general internal medicine, or general pediatrics. In contrast, in 1982, 39.6% of physicians planned careers in those areas.14 We are failing to meet the challenge to produce more primary care physicians for a number of reasons. First, we have not structured a physician payment system that pro¬ vides incentives for primary care. Instead, reimbursement practices disproportionately reward procedures at the ex¬ pense of cognitive services. Even with the advent of the Resource Based Relative Value Scale, this balance is unlikely to be redressed. We need to work to ensure more equity in physician incomes if the general and primary care specialties are to become more attractive as career options to our medical students.
References 1. Bennett CT, ed. 1989-90 AAMC Curriculum Directory. Washington, DC: Association of American Medical Colleges; 1989. 2. Wilson V, ed. 1983-84 AAMC Curriculum Directory. Washington, DC: Association of American Medical Colleges; 1983. 3. Petersdorf RG. Three precepts for professional life. Georgetown Med Bull. 1991;43:24-26. 4. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094. 5. Aschenbrener CA. Student honor codes in medical school. GSA
Reporter. 1990;20:4.
6. Cohen DL, McCullough LB, Kessel RWI, Apostolides AY, Alden ER, Heiderich KJ. Informed consent policies governing medical students' interaction with patients. J Med Educ. 1987;62:789-798. 7. Bennett IL. The continuum of medical education. J Med Educ. 1973; 48:40-48. 8. Voltaire F-M. Quoted by: Strauss MB, ed. Familiar Medical Quotations. Boston, Mass: Little Brown & Co Inc; 1968:400. 9. Smith LH. Medicine as an art. In: Wyngaarden JB, Smith LH, eds. Cecil Textbook of Medicine. Philadelphia, Pa: WB Saunders Co; 1985: 1-4. 10. American Board of Internal Medicine. A Guide to Awareness and Evaluation of Humanistic Qualities in the Internist. Portland, Ore: American Board of Internal Medicine; 1985. 11. Association of American Medical Colleges. 1990 Medical Student Graduation Questionnaires. Washington, DC: Association of American Medical Colleges; 1990. 12. Coulehan JL. Dissecting the clinical art. Pharos. 1984;47:21-25. 13. Odegaard CE. Dear Doctor: A Personal Letter to a Physician. Menlo Park, Calif: Henry J. Kaiser Family Foundation; 1986. 14. Petersdorf RG. In defense of medicine. Pharos. 1991:54:2-7.
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Educating a Medical
Professional Who Cares?
Robert G. Petersdorf, MD, Kathleen Turner, MPA \s=b\ We examined four domains in which physicians must demonstrate their capacity for caring. These include the knowledge base that forms the foundation for the practice of medicine, the personal characteristics and attributes that a physician brings to the profession, the individual patients for whom the physician accepts responsibility, and the society in which the physician lives. We conclude that the system of medical education does produce caring physicians. The profession's history of self-evaluation and criticism should not obscure medicine's real success in meeting its responsibility to care as well as to cure.
(AJDC. 1992;146:1338-1341)
education of medical professionals must be con¬ cerned with caring as well as curing. In this era of high-technological medicine, the American system of med¬ ical education has not always done the best possible job in
The
preparing caring physicians. Probably the first question to consider is what young medical professionals should care about. There are four important domains about which physicians should care. They include the following: (1) the knowledge base that forms the foundation for the practice of medicine, (2) the personal characteristics and attributes that a physician brings to the profession, (3) the individual patients for whom the physician accepts responsibility, and (4) the so¬ ciety in which the physician lives. KNOWLEDGE BASE knowledge base about which a physician should care can be narrowly defined as the curricular content of medical school and residency training. A more liberal view is that young physicians should care that their total academic preparation educates them as well-rounded cit¬ izens with a broad perspective on both their society and their profession. While our medical students and residents care about the knowledge base that will support their practice of medicine, it is less certain that they are convinced of the professional value of a broadly based ed¬ ucation. If they were, 70% of our medical school applicants The
1992. From the Association of American Medical Colleges, Washington, DC. Adapted from the Commencement Address, Tulane University, New Orleans, La, June 6, 1992. Reprint requests to the Association of American Medical Colleges, 2450 N St NW, Washington, DC (Dr Petersdorf).
Accepted for publication August 13,
would not be majoring in science at the baccalaureate level. In general, graduates of US medical schools receive an excellent education. The system of peer review and eval¬ uation of medical education as exercised by the Liaison Committee on Medical Education (LCME) ensures a rela¬ tively uniform standard of quality. The standards promul¬ gated and monitored by the LCME reflect a community consensus about the core curriculum and subjects that are essential to the awarding of the medical degree. The fact that 96% of medical students are graduated speaks elo¬ quently both to the quality of the young men and women attracted to medicine as a career and to the care that goes into their education. American medical education is particularly excellent in the preparation of students in the basic biomedicai sciences and in the clerkships that form the core experiences of clinical education. Our system of medical education has always recognized the importance of physicians having a firm grounding in basic science, followed by a period of supervised, hands-on instruction. Even the most cursory examination of American medical education reveals that medical schools produce young physicians who are well educated in medicine. However, it is much more difficult to respond yes to the question whether our students are broadly educated. All too often a career in medicine is launched in the rigid premedical educational environment that prevails in colleges and universities. Students become study machines, char¬ acterized as hypercompetitive and narrow-minded at best, and greedy and dishonest at worst. They are thought to be interested only in courses they believe will ensure their admission to medical school. Students in college should be broadening their educational background, experimenting in the study of a number of disciplines, and setting their minds to new intellectual horizons. Instead, we hear too often of students who will not consider an intellectually challenging course for fear of getting a poor grade and hurting their chances of admission to medical school. Faculties at medical schools should also be thinking about the signals they send to their medical students. When presenting information in the basic sciences, do they correlate it with the care of future patients? Or do they say, "Learn this; it will be on the National Boards"? Do exam¬ inations reward fact grubbing, or do they encourage inte¬ grative thinking? Our students are bright and competitive, and we must be attentive to the underlying messages transmitted to them about the knowledge base. We want our students to care about the knowledge presented them
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
because of its relevance to their future careers, not because of a single examination or their relative class standing. To accomplish this, we must be prepared to make some changes in the way medical education is structured. Med¬ icine has been extraordinarily fortunate because we have consistently been able to attract the best and brightest of our young people—by definition, people who can think. Regrettably, however, medical curricula have done little to teach students how to think. Our failure has been that we have emphasized rote learning and have relied too heavily on didactic presentations as the preferred pedagogical method. There has been an elemental gap between the ba¬ sic science years and the clinical years, and we have not been very successful in integrating those two stages of medical education. We are beginning to see change. The shortcomings of the didactic lecture as a teaching tool are a matter of record, especially in preparing for a profession whose practitio¬ ners must develop the habit of lifelong learning to main¬ tain professional competence. Although our faculties seem able to support this reform in principle, when it comes to hard decisions about what gets dropped from the curric¬ ulum, consensus evaporates. The Association of American Medical Colleges' (AAMC) curriculum directories indicate that from 1983 to 1989 the mean number of scheduled hours for required first-year courses decreased from 933.6 hours to 854.5 hours. Mean lecture hours declined from 465.3 to 440.8.u These changes are not monumental, but at least they signal a move in the right direction. We know our medical students care about their level of knowledge. A walk through any student lounge the day before an examination will confirm that. What is more im¬ portant is that they understand the importance of this cog¬ nitive base in the context of a longer professional career. A medical professional must be a lifelong learner. Physicians must care about their fund of knowledge, because they cannot be competent in the practice of medicine if this ba¬ sic professional tool becomes obsolete. The message we convey to students must be that the knowledge they acquire in medical school is not a sterile exercise in mem¬ orization but that it relates to their future patients. It is a living body that requires constant attention and review. How successful are we in relaying this to medical students? Perhaps we should be content with the observa¬ tion that they do care about the knowledge base, that they recognize its importance, and that they do well in acquir¬ ing that knowledge base and accomplishing our curricular objectives. However, the profession would be improved if all physicians were more broadly educated and able to place their professional knowledge within a larger intel¬ lectual context.
build their professional lives. With the privileges of being a physician go certain responsibilities, and failure to meet those responsibilities can exact a heavy price from the so¬ ciety on whose goodwill our professional privileges rest. Let us mention two instances in which the loss of integrity has done irreparable harm to our profession and bodes ill for its future. A decade ago the scientific world was stunned by the revelation that nearly the entire corpus of scientific publi¬ cation by a medical school faculty member was fraudulent. This was no honest disagreement on the interpretation of data or an accidental laboratory error that obfuscated the experimental results. It was a deliberate attempt to achieve personal advance by betraying the principles of scientific inquiry. That infamous case has been followed by others, perhaps less notorious, although no less nefarious. In re¬ sponse, a shaken scientific community has initiated a reexamination of professional peer review, scientific pub¬ lishing, and policies for investigating allegations of mis¬ conduct. However, the damage is done. The special place biomedicai research has held in the public's eye has been irreparably sullied by the revelation that some in the pro¬ fession have placed their personal ambitions ahead of their
PERSONAL CHARACTERISTICS AND ATTRIBUTES A distinguishing feature of a profession such as medi¬ cine is that there is a code of ethical behavior that, if not unique to the medical profession, is at least required of those who practice it. The Hippocratic oath represents the core of ethics for the physician, who is expected to be not
physicians?
only a knowledgeable
and well-educated individual but also one of demonstrated honesty and integrity. The ques¬ tion whether our students care about the personal charac¬ teristics and attributes of a physician is more difficult to answer than the question whether they care about their knowledge base. Integrity must be the cornerstone on which physicians
integrity.
Some individuals who aspire to careers in medicine ap¬ pear willing to go to any lengths to achieve their goals. For several recent examination cycles the examination that foreign medical graduates need to pass to qualify for house staff training in this country has been pilfered and is for sale "on the street" at $5000 per examination, and there is good evidence that some candidates achieved scores that defied credibility and that could not be sustained on sub¬ sequent examinations. The epidemic of thievery has ex¬ panded to the AAMC's Medical College Admission Test (MCAT) and the National Boards. At its first administra¬ tion in April 1991, the new version of the MCAT was pur¬ loined from a supposedly safe test center. Of course, the examination has been rewritten, but where is the integrity of some individuals who are willing to cheat a profession before they even enter it?3 An interesting discussion surfaced recently in response to an article published in the Journal of the American Med¬ ical Association4 that reported that only 54% of residents discussed their most significant mistake with their attend¬ ing physician. The article also indicated that those who ac¬ cepted responsibility for mistakes and discussed them
likely to report constructive changes in practice. It leads one to wonder about the motivation of these young physicians during their residency. Are they more inter¬ ested in getting through the period without embarrass¬ ment, or do they see this period as part of the medical ed¬ ucation process that will prepare them to be better
were more
It is facile to talk about the breakdown in moral values our society, but even if this is the case, it is not possible for the medical profession to accept a lowered standard of ethical conduct. If, indeed, society, the family, or the edu¬ cational system is not fostering ethical values in its mem¬ bers, then the medical profession, through its educational system and the socialization of new members of the pro¬ fession, must attempt to fill the void. We must worry about whether medical students care about personal attributes and characteristics that are essential to the profession of medicine. Medical education in recent years has attempted to introduce more teaching in
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ethical issues in the curriculum. However, most of the work on medical ethics concentrates on patient care issues, and devotes little time to common medical student dilemmas, the study of which might improve medical stu¬ dents' moral reasoning. For example, a 1990 report5 revealed that fewer than half of medical schools have a student honor code. Studies of medical students show substantial disagreement about whether particular behaviors are unethical. In one study, only 38% believed "signing an attendance sheet for a friend" was wrong; 31% did not believe that copying a laboratory report from a friend was cheating.6 Especially troublesome for medical students and residents is the di¬ lemma they face when they observe unethical behavior in a peer. Our goal should be to encourage students to accept responsibility for the ethical climate, including responsi¬ bility for each other as professional colleagues. Faculty and institutional leadership at academic medical centers should consider several questions in their efforts to improve the moral and ethical environment: Do medical students witness and participate in be¬ haviors in conflict with professional ethics, such as differ¬ ent treatment for patients with private insurance, manip¬ ulation of diagnosis related groups for reimbursement purposes, or inappropriate relationships with pharmaceu¬ tical companies? Are examinations and evaluation procedures fair, thereby reducing peer pressure and minimizing the temp¬ tation to cheat? Are the ethical standards expected of students and residents clearly articulated and understood by them? Are there appropriate mechanisms for them to seek advice and report violations of these standards? Is the medical center supportive of cultural differ¬ ences, providing an atmosphere that is free of racism and sexism? Our medical students and residents can be educated to care about the personal attributes and characteristics of ethical physicians only if we as medical educators are pre¬ pared to provide a moral example for them. In his chair¬ man's address to the AAMC, Bennett7 made this point by quoting Sir William Osier: "This higher education so much needed today is not given in the school, is not to be bought in the market place, but it has to be wrought out in each one of us for himself; it is the silent influence of character on character. ..." on
course
•
•
•
•
CARING FOR PATIENTS Medicine is often described as having two separate components, ie, the science of medicine and the art of medicine. I have touched already on the science of medi¬ cine. Yet the physician's relationship with patients must also consider the art of medicine. What exactly is the art of medicine? There have been many definitions. Voltaire8 be¬ lieved it occurred when a physician "... successfully amuses his patients while Nature effects a cure." L. Holly Smith,9 former chairperson of medicine at the University of California, San Francisco, has another definition: "In the art of medicine the physician must be the advocate of the patient as well as the adversary of disease." To be an advocate for patients the physician must understand patients and know how to communicate with them. In recent years medicine has been criticized for be¬ ing too scientific and insufficiently humanistic. Some seem
to believe that science and
humanity are dichotomous and mutually exclusive, that technology and compassion can¬ not be found within a single physician. As medical profes¬
sionals we must refute this belief. In 1985 the American Board of Internal Medicine ap¬ proved a guide to awareness and evaluation of humanis¬ tic qualities in the internist.10 This action is important in two respects. First, it recognized that the knowledge base for medicine is not exclusively scientific. Second, it ex¬ pressed a belief that humanism in medicine can be actively
taught.
Medicine has apparently had no trouble in teaching its acolytes to be inhuman. New medical students are almost uniformly idealistic and motivated to serve their fellow human beings. Yet somewhere in the medical education process a large number of them seem to become hardened and cynical, skeptical about the value of the art of medi¬ cine. Perhaps this occurs because of the overwhelming emphasis medical schools place on biomedicai science and because of the stressful physical demands of the residency
years. Students
of this, and they fear the loss of see that they as the natural outgrowth of ad¬ compassion vancement in medical education. Each year the AAMC polls graduating medical school seniors.11 The question¬ naire is extensive, collecting information on their back¬ ground, their training and career plans, how their medical education was financed, and their experiences in medical school. Among the questions is one that asks students to rate the time they spent in various subjects during medical school as excessive, appropriate, or inadequate. The graduates overwhelmingly rank as excessive the time devoted to ba¬ sic medical sciences information. On the other hand, among the topics viewed by those same graduates as re¬ ceiving inadequate attention during undergraduate med¬ ical education are management of the patient's socioeco¬ nomic, educational, and emotional problems; effective patient education; therapeutic management; the role of medicine in the community; independent learning and self-evaluation skills; and patient interviewing skills. It seems clear from these data that medical students do care about the art of medicine. Furthermore, they recognize that the medical schools seem unable to help prepare them in this important respect. Coulehan12 has noted, "Curricu¬ lum to teach the clinical art suffers from expansion of the disease-oriented curriculum, but also its own conceptual weakness. Our art, though hoary with age, has been almost entirely grounded in tacit knowledge. It has not been well formulated into intelligible and systematic components." The biopsychosocial approach to medicine emphasizes the relevance of both the social and natural sciences to medicine. We do a disservice to our students when we ig¬ nore or downplay one of these elements. Students want very much to be caring physicians, but we do not do much to help them. In Dear Doctor Odegaard13 wrote, "... the process of education for the physician's role has not pro¬ vided sufficient instruction on the human relationship be¬ tween the patient and the physician." A recently released movie expands on this theme. The film depicts an arrogant, omniscient physician who learns to be humanistic and caring only after he himself becomes a patient with a lifethreatening illness. Surely, as a teaching tool this example may be too extreme, but its shock value is indisputable. Somehow we must do better in responding to students' are aware
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desire to care,
patients.
emotionally as well as physically, for their
RESPONSE TO SOCIETY'S CONCERNS Medicine is frequently accused of being uncaring about society's needs. For the most part, this characterization is unfair. Much of the blame for societal ills, such as the lack of access to the health care system for 35 million Ameri¬ cans, spotty care for the indigent, high neonatal mortality, and high health care costs, has been laid at the door of medicine. Medicine is not to blame for such social blights as substance abuse, the crime that follows in its wake, homelessness, poverty, urban decay, rural deprivation, and illiteracy. These are matters in which the body politic has failed because it has systematically starved the social infrastructure so laboriously constructed in the 1950s, 1960s, and 1970s. It has also failed to impose the discipline required to solve some of these problems. Rhetoric will not do it; sensible and fair taxes that we, the people, are will¬ ing to pay might. An example of where medicine has done its part has been in the dreaded scourge of the 1980s, the acquired im¬ munodeficiency syndrome. In just a decade scientists have identified the virus, elucidated how it works, and found ways to contain it. A cure, or at least better containment and prevention, is a feasible agenda for the 1990s. With the exception of some fear-engendered failures to care for pa¬ tients with the acquired immunodeficiency syndrome, the medical profession has played its role well, and, for the most
part,
our
A second
for the failure to produce primary care be that physicians may primary care has not been a valued activity of academic medical centers. When asked why they selected a particular specialty, graduating seniors frequently cite the influence of a positive educational ex¬ perience or the personal example of a role model. We must wonder just how much exposure to primary care medicine and its practitioners our students receive in the tertiary care, technologically sophisticated modern academic med¬ ical center. Physicians do care about society's needs, particularly the curing of disease and the restoration of health. While the profession has been unable to address the primary care is¬ sue, individual physicians cannot be blamed for this fail¬ ure. It is the leadership of academe and the medical care system that have failed to instill a sense of value and importance for that much-needed component of our reason
profession.
COMMENT Are we educating medical professionals who care about themselves as physicians, about their patients, and about society? For the most part, we are, although there is always room for improvement. Medicine has a long history of self-examination and criticism directed toward improving the profession. We should not allow this tendency and the observations it illuminates to obscure our very real successes.
hospitals, particularly teaching hospitals,
have met the crisis responsibly and humanely. While long-term care for these desperately ill patients still leaves a lot to be desired, it is improving. That is not to say that we can look at medicine's record with complete satisfaction. We still have a long way to go to come up to societal expectations. An example is the publicly perceived and often articulated need to train more primary care physicians. With some notable exceptions we are not doing it. In 1990 only 26.3% of our medical school graduates indicated that they intended to pursue a career in general practice, family medicine, general internal medicine, or general pediatrics. In contrast, in 1982, 39.6% of physicians planned careers in those areas.14 We are failing to meet the challenge to produce more primary care physicians for a number of reasons. First, we have not structured a physician payment system that pro¬ vides incentives for primary care. Instead, reimbursement practices disproportionately reward procedures at the ex¬ pense of cognitive services. Even with the advent of the Resource Based Relative Value Scale, this balance is unlikely to be redressed. We need to work to ensure more equity in physician incomes if the general and primary care specialties are to become more attractive as career options to our medical students.
References 1. Bennett CT, ed. 1989-90 AAMC Curriculum Directory. Washington, DC: Association of American Medical Colleges; 1989. 2. Wilson V, ed. 1983-84 AAMC Curriculum Directory. Washington, DC: Association of American Medical Colleges; 1983. 3. Petersdorf RG. Three precepts for professional life. Georgetown Med Bull. 1991;43:24-26. 4. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094. 5. Aschenbrener CA. Student honor codes in medical school. GSA
Reporter. 1990;20:4.
6. Cohen DL, McCullough LB, Kessel RWI, Apostolides AY, Alden ER, Heiderich KJ. Informed consent policies governing medical students' interaction with patients. J Med Educ. 1987;62:789-798. 7. Bennett IL. The continuum of medical education. J Med Educ. 1973; 48:40-48. 8. Voltaire F-M. Quoted by: Strauss MB, ed. Familiar Medical Quotations. Boston, Mass: Little Brown & Co Inc; 1968:400. 9. Smith LH. Medicine as an art. In: Wyngaarden JB, Smith LH, eds. Cecil Textbook of Medicine. Philadelphia, Pa: WB Saunders Co; 1985: 1-4. 10. American Board of Internal Medicine. A Guide to Awareness and Evaluation of Humanistic Qualities in the Internist. Portland, Ore: American Board of Internal Medicine; 1985. 11. Association of American Medical Colleges. 1990 Medical Student Graduation Questionnaires. Washington, DC: Association of American Medical Colleges; 1990. 12. Coulehan JL. Dissecting the clinical art. Pharos. 1984;47:21-25. 13. Odegaard CE. Dear Doctor: A Personal Letter to a Physician. Menlo Park, Calif: Henry J. Kaiser Family Foundation; 1986. 14. Petersdorf RG. In defense of medicine. Pharos. 1991:54:2-7.
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