Revitalising Professionalism

Seggie J. Revitalising professionalism. S. Afr. Med. J. 2011 Aug.;101(8):508–509. PMID 21920118

This is yet another cracker from R&R in the Fast Lane via Sa’ad Lahri. There’s not a chance I would have found this paper otherwise so go check it out.

It’s a short, narrative review of some of the debate surrounding the nature of medical education and in particular the idea and definition of what it means for medicine to be a profession.

Some nice quotes:

professionalism is ‘a set of values, behaviours, and relationships that underpin the trust the public has in doctors’

learning of professional behaviour and absorption of professional values depends on strong, engaged relationships with positive role models

there should exist a moral contract between the medical profession and society

I want to talk a little bit more about the last one, about what the “moral contract” bit might mean.

I read a lot of a chap called Hauerwas and he describes medicine as drawing it’s moral authority from a society that refuses to abandon others who need help. Our society dedicates large amounts of money and some of its finest people to care for the ill – this in itself is a profound moral statement. Now I know that there are sound societal, economic reasons for doing health care but I really don’t think that’s why groups of humans do it.

The fact that medicine rarely cures many of the diseases that we attend to makes it even more morally significant.

For us to remain a profession (as opposed to being technicians) we must not neglect the moral aspect of what we do.

Here’s a Hauerwas quote for you to ponder.

Medicine is a profession determined by the moral commitment to care for the ill… The ability to sustain such care in the face of suffering and death is no easy enterprise, for the constant temptation is to try to eliminate suffering through the agency of medicine rather than let medicine be the way that we care for each other in our suffering… Indeed I suspect the increasing technological character of medicine with the correlative growth in specialisation reflects the attempt to substitue scientific expertise for the moral commitment necessary to maintain medicine as a coherent profession.

Suffering Presence 

Notre Dame Press: 1986; P17

Before anyone gets too upset, a moral commitment to care for the ill in no way prohibits technology or scientific expertise or so many of the things that I think really matter about emergency medicine, but in a rather twee and inadequate aphorism we need to be willing and open to care before we can cure.


UPDATE: Domhnall has written on something similar before so go read it too.

Bioethics in medical education

Ethics is tricksy.

No way round it.

There are lots of reasons for that, the type of thing that keeps philosophy and ethics departments in good work.

Approaches to ethics in med school are always going to be hopelessly inadequate, it’s perhaps unfair to expect much else.

This paper discusses ethics and how to train people in ethics in EM. And they say lots of good things. It’s just that it’s a tad reductionist for my liking.

Ethics curriculum for emergency medicine graduate medical education. J Emerg Med. 2011 May;40(5):550-6. Epub 2010 Oct 2. PMID 20888722

Fig 1 from the paper

That figure may make a lot of sense to you. It certainly makes sense to me I’m just not sure it’s an entirely appropriate way to teach ethics or indeed practice it.

Or maybe it is. It’s probably a perfectly decent way to teach ethics if you believe that ethics is just another abstracted category to be put alongside physiology and anatomy.

The authors make this quote

a sound understanding of the principles of bioethics is necessary to become a compassionate and effective physician

Here I disagree. I do not know how an understanding of bioethics makes a doctor more or less compassionate.

Compassion in the context of virtue, character and humanity may be a learnable skill through the practice of a life lived but I’m not sure it’s teachable in the sense you can pass an MCQ at the end of it.

They do mention one thing that might be good material for fruitful reflection

Ethics education can be effectively provided, not only through behaviour modelling in the clinical environment, but also in formal didactic instruction

While I think the didactic instruction has its limitations as discussed above I think the “behaviour modelling” is fascinating.

Which brings me to this paper:

A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Ann Emerg Med. 2011 May 28. [Epub ahead of print] PMID 21624702

Medicine is a lot like apprenticeship. In the sense that personalities and relationships are a key part of our learning and skill development. I model the behaviour and knowledge and skills that I find in my seniors.

These guys called the modelled professionalism by seniors “the hidden curriculum” which is kind of a neat name. Basically the students take on the habits of the seniors and the practices observed.

I am deeply grateful to the people I have worked with both for the things that they have taught me to do and the things that I have seen them do and vowed never to repeat!

The term “holistic” is in vogue when it comes to talking about patients. It’s unfortunate that it’s become a buzzword as it’s actually a useful reminder that we treat people, not just patients, and certainly not conditions.

To think of ethics training and the practice of medicine as easily definable and teachable components that can be formed in an algorithm is something I find quite inadequate.

Some (tongue in cheek) conflicts of interest:

  • I think medical training is there to produce people capable of caring for the suffering, sick and the dying. These people need to both retain their own humanity and help their patients retain theirs. (This need not be in conflict with the good science and practices that fill medical research journals)
  • As background to this I am not a materialistic determinist. I have problems with a lot of the assumptions modernity has given us. I am a confessing Christian and a big fan of virute ethics. Though I’ll gladly admit Aristotle was a bit bonkers on a whole range of things…
  • I’m starting a masters in theology in the hope of exploring this kind of thing a bit further. And hopefully make it in some way intelligible and not just vague allusions to Macintyre

Medicine as virtue formation

Did you see this? Atul Gawande’s speech at commencement at Harvard Medical school a few weeks back.

If you want something to go well with it then read this by David Brooks in the NY Times.

If you want something heavier than that then read this or even this but then it starts getting really dense.

Let me give you a few starters from Gawande:

The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors

His advice:

  • measure where you succeed and fail; become interested in data (see his book Better)
  • develop abilities to provide solutions for systems problems that come from the data (he quotes the check list idea)
  • be able to get colleagues to work like a “pit-crew” for patients; he mentions humility, team work and  discipline
These values are the opposite of autonomy, independency, self-sufficiency.
Which leads me to David Brooks:
If you sample some of the commencement addresses being broadcast on C-Span these days, you see that many graduates are told to: Follow your passion, chart your own course, march to the beat of your own drummer, follow your dreams and find yourself. This is the litany of expressive individualism, which is still the dominant note in American culture.
and my favourite:
Most people don’t form a self and then lead a life. They are called by a problem, and the self is constructed gradually by their calling.
Stanley Hauerwas, who is the major reason I’m studying for a theology masters talks a lot about the practice of medicine as being a much better place for moral formation than seminary. Health care in its very existence is a moral practice that is a bridge between the healthy and sick so that the sick are not alone; that the sick know that they are still part of their community of fellow humans. In order to maintain medicine as a morally significant practice; as a deeply human process, and not descend to become a group of “technicians” requires many of the navigational skills (or as I’d prefer – virtues) that both Brooks and Gawande suggest.

Note to self: Don’t die

[Title referencing this song, of course. Back from when I used to title every blog post by song titles. Previously posted over here]

[If you’ve sat and talked to me lately you’ll realise that this has been floating round my head for a while. Time to fumble with the words for it.]

I spend a lot of time thinking about medicine. Sometimes I think I’d prefer to spend my time thinking about medicine than practising it. My thinking about medicine has changed fairly significantly since I started on this 11 years ago.

I entered medical school as a naive enthusiastic teenager doing medicine because I didn’t have any better ideas. I spent 5 years pissing about, playing footy, music and mario-kart and enjoyed it thoroughly and learnt nothing. I started work as an only slightly less naive 23 year old and made lots of mistakes and had my eyes opened to the ravages of disease that run rampant through these fragile, scared human beings. I learnt the techniques and the lingo and threw all that technology had to throw at people often because it was easier to do something than stop and talk and think.

And then I moved to NZ and had an ocean of space and time to learn, think and work with some cool people and it started to have a big impact on what I thought about it.

I saw people declared brain dead and their organs removed and lives saved because of it. I watched many people pass from life to death. I had patients I really, really liked die on me just a few months after we’d busted a gut (sometimes literally) to get them better. I spoke to endless relatives, I perfected my sympathetic active listening. I told lots of people their loved ones were dead.

I came home and dad got sick and I experience most of the above from a relatives point of view. He always said “why not me?”

Dad died.

I went back to work a slightly different doctor. I wept a lot easier. I got incredibly angry at some of the regular stresses, discomforts and humiliation that we put patients through on a regular basis.

I got good at my job. I’m perhaps not the person to ask but I think I got pretty good at it.

And all through this I thought and read. Vonnegut,  Hauerwas, Marilynne Robinson, Wendell Berry .

I listened to lots of podcasts on evidence based medicine and came away thinking that even the “evidence” doesn’t support most of the silly things we do. At least not in a way that the people we do the things to would care about if we told them the truth.

I got married.

I quit work and the space between changed me again.

Let me try to summarise where I stand and I’ll see if I can unpack it later over a few posts:

  • In modern (for the sake of this I mean the past 50/60 years, though it is more apparent recently) society we believe in a certain sense of entitlement – an entitlement to our four score years and ten. Pensions, retirement, leisure time have all contributed to it, but I beleive modern medicine is the most powerful driving force behind this idea that all human beings have a right to 80 years of health and die peacefully in their sleep
  • as a result  we are unsure of what to make of it and feel no way of understanding our own deaths or those of others in the context of the narratives we identify with in many other aspects of our lives. To try and simplify – we let medicine tell us who we are, how we should live and how we should die.
  • we attribute to modern medicine power and glory because we believe it deserves it. Doctors are happy to show us how wonderful they are and we are keen to believe their story.
  • those with faith convictions often appear as scared and confused by early death as non-believers. People who believe in the sovereignty and goodness of God often seem to find their hope in medicine than God. Or put it this way – God will do fine if medicine doesn’t work.
  • In allowing modern medicine such significance and power in our lives and society (sometimes with better reasons than others) we do violence to our own and others humanity
  • as cynical and critical as I am of big pharma I also believe that doctors (often the most powerul lobby amongst health professionals) are key to this.
  • having said that I believe that the medical-industrial-complex is only so because we want it that way. We want to believe the narrative we’re being sold.

I’m not about to quit the profession or anything – I love the job, in fact I feel more than ever the weight and importance of the job and our relation to how we define health and health care.

It does affect me personally though. Whether I like it or not, part of my identity is linked to this. This affects who I am.

These are just some things that have been going through my head. If anyone has any thoughts of how I could develop this a bit further – in the context of books or even how I could study this in an academic setting then I’d love to hear from you.