Rambling About Teaching Professionalism in Medicine

I want to let you know about a relatively new feature of the Arnold P. Gold Foundation, which is a blog, Humanizing Medicine – The blog of the Arnold P. Gold Foundation. I have a link to it above the Header on my home page. I had a quick look at the August post, “Want more docs in primary care? Send ‘em to the country first,” which was a list of important studies in teaching humanism and professionalism in medicine. One of the articles about teaching professionalism piqued my interest so I read it through quickly [1]. Some of what I found there reminded me of a few of my great many flaws as a teacher and role model–so I pressed on. I hope I don’t just ramble here.

The Birden review reminded me of the difference (sometimes the great difference), between what medical students are taught in the early years and what they learn in the later years of medical school. I suppose one of the best references in the review would probably be the one I didn’t take the time to read although the authors of the Birden paper wrote one paragraph about it that resonated with my experience as a medical student and as a practicing psychiatrist on faculty in an academic medical center:

Coulehan and Williams criticise contemporary professionalism education as ‘too little, too soon, too late, too distant, and too countercultural’ (2003, p. 14). Too soon, because it is generally included in the first years of the medical curriculum alongside the rote memorisation of facts required by anatomy, physiology, and the other hard sciences of medicine, and so gets glossed over as a priority. Too late because by the time reflection on professionalism takes place, the socialisation process of the harsh work of clinical practice, especially in hospitals, has hard wired the student into attitudes, behaviours, and thought patterns that are the antithesis of professional. Too distant because case scenarios discussed in class often bear little resemblance to the much more nuanced situations in real clinical practice and even if not are presented without the pressures of having to placate an authority figure. Too countercultural because ‘the culture of clinical training is often hostile to professional virtue’ (p. 14).

The “hidden curriculum” is what Birden and colleagues called what is referred to as the “culture” in the last sentence. I remember my Neurology clinical clerkship and my senior resident. His way of teaching me how to insert a foley catheter reminded me of what some people say about sausages and laws–you don’t really want to see how they’re made. That’s not an excuse. I’m just rambling to make a point.

One of the studies they reviewed included quotes from the essays of medical students obviously penned at the time of the “hidden curriculum.”

Wear and Zarconi (2008) found reasons for both dismay and hope in a study on student views of professionalism teaching. Asking students to allow them to review for research purposes capstone essays which were required for these students’ training programmes, they got about half to accept. From these essays, Wear and Zarconi gleaned that students were sick and tired of professionalism being ‘shoved down our throats’ (p. 950). They considered that they came to medical school with compassion and altruism, but had these qualities assaulted and challenged, largely through clinical experiences in systems where productivity and efficiency, ‘an assembly line mentality’ (p. 951), were everything, compassion and empathy nothing. They recommended grooming more competent role models for the task and ensuring that students are afforded opportunities to de-brief and critically reflect on their experience, both positive and negative, with trusted faculty. Stephenson’s group (Stephenson et al. 2006) found a similar effect: that clinical ‘hidden curriculum’ experiences often negate carefully developed professionalism teaching in earlier pre-clinical years.

The authors tried to find their “gold standard” study of professionalism:

Our ‘gold standard’, the highest grade of evidence that we searched for, consisted of studies reporting on a teaching method or set of methods that produced a verified increase in some measure of professionalism, either qualitative or quantitative, over multiple years across a range of medical schools. We found none.
However, there were some high points. One of the programs seemed to get high marks; and it’s called “The Healer’s Art”, an elective developed in the early 1990s at The University of California. It’s been adopted at many schools across America and Canada.
Although there’s no consensus on the best way to teach professionalism in medicine, role modeling and mentoring are the important elements, according to the conclusions of Birden and colleagues. There’s no one-size-fits-all curriculum and each institution probably has to find the best way to teach it so as to fit its situation.
Maybe it’s just as important to define what we mean by “hidden curriculum” as by “professionalism.” If we were to reflect on and define the “hidden curriculum”, and search for the systemic and cultural biases coloring the curriculum, it could be easier to become a mentor and to find one.

1. Birden, H., N. Glass, et al. (2013). “Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25.” Med Teach 35(7): e1252-1266.

Introduction: We undertook a systematic review to identify the best evidence for how professionalism in medicine should be taught. Methods: Eligible studies included any articles published between 1999 and 2009 inclusive. We reviewed papers presenting viewpoints and opinions as well as empirical research. We performed a comparative and thematic synthesis on all papers meeting inclusion criteria in order to capture the best available evidence on how to teach professionalism. Results: We identified 217 papers on how to teach professionalism. Of these, we determined 43 to be best evidence. Few studies provided comprehensive evaluation or assessment data demonstrating success. As yet, there has not emerged a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum. Discussion: Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programmes, and are widely held to be the most effective techniques for developing professionalism. While it is generally held that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory.



  1. Jim – I think that the medical students surveyed here have a point. There is nothing worse for morale or the implicit teaching of professionalism than someone suggesting that it encompases being cost effective, productive and an overall “good steward of the resources.” All any enterprising medical student needs to see is the decimation of psychiatry by managed care and unimaginative administrators.

    The interpersonal dimension here is critical as well. I am a better doctor because I had great teachers who I identified with and internalized their important intellectual and professional characteristics. I saw how they interacted with patients. I noted their responsibility to the patient and how they proceeded to help the patient. That landscape has been altered by business interests who want physicians to act like they are business men. As far as I can tell that doesn’t make any sense, especially in psychiatry where we are looking at “cost effective” in the rear view mirror. I have a few ideas about it in my post on changing the structure of the residency. (below)


%d bloggers like this: