Good family doctors are made not born: An overview of teaching and learning about professionalism in family medicin

John Yaphe

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Rev Port Clin Geral 2011;27:497-8497editorialtions of professionalism used by the bodies charged withthe responsibility of training doctors, namely faculties ofmedicine. For example, the Northeastern Ohio Universi-ties College of Medicine sees professionalism as reliabi-lity and responsibility, honesty and integrity, maturity, respect for others, altruism, interpersonal skills, and theabsence of impairment either psychological or chemical(as in alcoholism or drug abuse). The definition from theUniversity of California at San Francisco includes a com-mitment to self-improvement and adaptability, excellentrelationships with patients and families and with othermembers of the health care team. If we look closely at these items, we will see that thereare five clusters of professionalism in medicine.4 Theseare: adherence to ethical practice principles, effective in-teractions with patients and families, effective interac-tions with people working within the health system, reli-ability, and commitment to autonomous improvement ofcompetence in oneself, others, and health care systems.Many of these definitions were developed by expertbodies creating mission statement, by surveys or by aDelphi process. It has been possible to test these criteriausing case vignettes.5 When presented with cases illus-trating lapses in professional behaviour such as a lack ofaccountability, tardiness, lapses in excellence, inappro-priate dress, laziness, dishonesty, disrespect, and im-pairment, physicians are generally in agreement. How-ever there may be wide variation in scores for any item,independent of age, gender or stage of training. Thesefinding suggest there is much work to be done in achie-ving agreement on the elements of professionalism.*Dr. John Yaphe, Associate Professor, Community Health, School of Health Sciences,University of Minho, Braga, PortugalJohn Yaphe*Good family doctors are madenot born: An overview ofteaching and learning aboutprofessionalism in familymedicineAre good family doctors born or made? Can weteach the knowledge, skills and attitudes neces-sary to become a professional, proficient fami-ly doctor? There is much that we do not knowabout how this happens or how to make this happen.The reader is invited to reflect on the growing body of li-terature on teaching, learning, assessing and evaluatingthe effects of professionalism in medicine. It is worth ex-ploring this challenging issue.We have a hard time defining professionalism inmedicine, let alone teaching or assessing it effectively.Family medicine has many definitions that are bound upin culture, tradition and history and there is no one ac-cepted definition. The European definition of general practice adoptedby WONCA1 provides an important first step in under-standing professionalism as does the EURACT educa-tional agenda2 that was based on this definition. There aremany items in the definition and the agenda that relateto the knowledge behaviour and attitudes of family doc-tors that can be fused into a definition of professionalism. What is good family medicine and who is a good fa-mily doctor? That is one way to begin reflection on thenature of professionalism. There is a long list of attributesof good medicine and good doctors with general agree-ment on these items.A profession is a vocation with a body of knowledgeand skills put into service for the good of others, usuallycharacterized by self-regulation.3There are many defini-There are good reasons for this lack of agreement be-cause the nature of professionalism changes as societychanges as Sean Hilton has observed.6The values of trust,competence, ethical practice, integrity, honesty, altru-ism and vocation remain unchanged. Other profession-al values such as internal self regulation have moved toaccountability and openness. The former value of mas-tery of knowledge has changed to a credo of continuingprofessional development. There have been majorchanges from paternalism to partnership and mutuali-ty, from tribalism to collegiality and from self-sacrifice toshared responsibility. The changes all require modifica-tions in the medical curriculum to prepare new doctorsfor a changed society and a changed profession.How then do we teach the new professionalism inmedical schools? By 1999, over 90% of medical schoolsin the US had some formal teaching about professional-ism in the curriculum.7There are rites of passage such asthe white coat ceremony or the swearing of oaths. Mostmedical schools teach the subordination of one’s self in-terests, adherence to high ethical and moral standards,response to societal needs, and demonstration of evin-cible core humanistic values. Learning the “healer’s art”includes the development of the person. This topic re-quires new methods such as small group learning and re-flection and new attitudes to relationship-centered careto promote their development in students.8Episodes of television medical dramas such as “Gray’sAnatomy” have also been used to teach doctor-patientcommunication and inter-professional communication.9Guided reflection on critical incidents witnessed du-ring training may be used to teach students about pro-fessionalism. Troubling events experienced in the cliniccan be turned into formative moments in the careers ofsome students.10There are many methods used for assessing profes-sionalism. Each of these methods possesses particularstrengths and combination of methods can produce avalid and reliable measure of professionalism. For ex-ample critical incident reports made by faculty regar-ding student behaviour with timely feedback can resultin remedial actions and improvement in professional be-haviour.11 Peer assessment has also shown students to bekeen and frank observers of their colleagues with regardto self-directed learning, interpersonal relationships andresponsibility.12 Self-assessment by trainees with regardto interpersonal relations and conveying information topatients has also been shown to be an effective method.13In conclusion, professionalism can be defined, taughtand assessed. While reflection by faculty on individual at-titudes and local needs is of value, there is also a richbody of published literature available to help medicalschools and training programs create an effective andrelevant curriculum in education for professionalism. (This editorial is based on a lecture presented to the20th international Bled course for teachers of FamilyMedicine held in Slovenia in September 2011. It was pub-lished in a modified format in Družinska Medicina 2011;9 (Suppl 4): 103-107 and is reprinted here with the per-mission of the Slovene Society of Family Medicine.)CONFLICT OF INTERESTNoneREFERENCES1. The European Definition of General Practice/Family Medicine, WONCA Europe2005. Policy Paper, Working Group from WONCA Europe and EURACT,http://www.euract.eu/official-documents/finish/3-official-documents/94-euro-pean-definition-of-general-practicefamily-medicine-2005-full-version (last ac-cessed 11 September 2011).2. Heyrman J, ed. EURACT Educational Agenda, European Academy of Teachers inGeneral Practice EURACT, Leuven 2005. http://www.euract.eu/official-docu-ments/finish/3-official-documents/93-euract-educational-agenda (last accessed11 September 2011)3. Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. AcadMed 2002 Jun; 77 (6): 502-15.4. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: resultsof a systematic review. Acad Med 2009 May; 84 (5): 551-8.5. Borrero S, McGinnis KA, McNeil M, Frank J, Conigliaro RL. Professionalism in res-idency training: is there a generation gap?. Teach Learn Med 2008 Jan-Mar; 20(1): 11-7.6. Hilton S. Education and the changing face of medical professionalism: from priestto mountain guide? Br J Gen Pract 2008 May; 58 (550): 353-61.7. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in un-dergraduate medical education. JAMA 1999 Sep 1; 282 (9): 830-2.8. Daaleman TP, Kinghorn WA, Newton WP, Meadorkg. Rethinking professionalismin medical education through formation. Fam Med 2011 May; 43 (5): 325-9.9. Pavlov A, Dahlquist GE. Teaching communication and professionalism using apopular medical drama. Fam Med 2010 Jan; 42 (1): 25-7.10. Stark P, Roberts C, Newble D, Bax N. Discovering professionalism through guid-ed reflection Med Teach 2006 Feb; 28 (1): e25-e31.11. Hodges D, McLachlan JC, Finn GM. Exploring reflective ‘critical incident’ docu-mentation of professionalism lapses in a medical undergraduate setting. BMCMed Educ 2009 Jul 15; 9: 44.12. Kovach RA, Resch DS, Verhulst SJ. Peer assessment of professionalism: a five-yearexperience in medical clerkship. J Gen Intern Med 2009 Jun: 24 (6): 742-6.13. Symons AB, Swanson A, McGuigan D, Orrange S, Akl EA. A tool for self-assess-ment of communication skills and professionalism in residents. BMC Med Educ2009 Jan 8; 9: 1.ENDEREÇO PARA CORRESPONDÊNCIAyonahyaphe@hotmail.comRev Port Clin Geral 2011;27:497-8editorial498

Good family doctors are made not born: An overview of teaching and learning about professionalism in family medicine

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Good family doctors are made not born: An overview of teaching and learning about professionalism in family medicine

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