Last August I sat surrounded by 163 other ambitious, new medical students on our “introduction to the profession” week. Anxiety was high with undertones of self-doubt mixed with lofty goals. Another distinguished figure had taken the floor to introduce us to the concept of medical professionalism: commitments to patient-centered care, intellectual honesty, social responsibility and advocacy. The long list of medical virtues we were to develop, cherish, and exemplify in our next four years and throughout our careers. The moral bar seemed set for a saint, and I began to question whether I belonged among my peers.
The importance of medical professionalism and student wellness has been stressed in many lectures, small group discussions, and other communication throughout our curriculum. But often our discussions about residency applications, health care spending, or the future of U.S. health care led to conflicting views about what commitments take priority. For as much as I heard the term “medical professional,” I must confess that no other concept in my first year of medical education was more elusive. I continue to struggle to understand how to uphold the altruistic virtues this field professes while attending to my own well-being. It seems I’m not alone. Each time I read debates about physician self-referral or dwindling reimbursements for services, I feel providers are caught between their commitments to patient care and personal interests.
Over the last 10 to 15 years there has been a fair amount of interest in defining medical professionalism and instilling these virtues in medical trainees as some fear that these virtues are being lost in the face of growing technology or business incentives. Authors have published “fundamental principles” and “core domains” of professional ideals, yet educators have struggled with the subtly and subjectivity of teaching and assessing professionalism. After all, an action is far easier to measure than an attitude or disposition. Consider “respect for patients.” I think there would be consensus among my classmates in valuing this medical virtue. Yet some would define this concept as complete patient autonomy whereas others would rely on some soft paternalism.
Perhaps a more important first step is allowing students to question and struggle with what medical professionalism means to them. While it may be tempting to try to fit teaching professionalism and wellness into a system akin to principle-based ethics and give students “skills and concrete rules,” a more honest reflection of professionalism and wellness development is that it requires students to go on their own journey to appreciate and internalize the values that they support in medicine and in their own lives.
Some may question the utility of such open discussions in place of pursuing consensus on concrete principles. I believe both have their place. I see value in articulating what virtues the medical community hopes to uphold; however, there can be distance between the virtues we view as important and those which motivate our actions. Physicians’ actions often hold significant moral weight. It can be easy to look at isolated examples of research misconduct or kickbacks from drug companies with condemnation and disassociation. That is part of the danger. I think most unprofessional behavior stems from incentives which many providers share: financial gains for one’s family, job security, personal validation. Principles can unfortunately be memorized and applied without adopting the values which lie beneath them. Openly discussing our attitudes and dispositions can help bring to light and remedy discrepancies between the values we agree to support and those our actions reflect.
I have had the opportunity to experience one discussion-based approach to medical professionalism and mental well-being as part of my institution’s new curriculum. Once per month we share blog posts on and meet to discuss topics related to our adjustment to the medical lifestyle, such as maintaining relationships or coping with stress. The path to a career in medicine can be a lonely one, full of vulnerability and self-doubt. These monthly meetings are not only explorations of professionalism but reminders that there are others struggling with us, both at our level and throughout their careers.
I believe this approach is very valuable. To be completely honest, my first year of medical school did not go as I intended. I expected rigorous academics, but instead found myself climbing a physically, emotionally, and mentally challenging mountain. Struggles within and outside my academic commitments pushed me to my breaking point. Looking ahead, I saw only loftier expectations which made me question whether mountain climbing was really for me. The medical professionals I saw initially seemed invulnerable, but it took time and discussion to appreciate the insecurities and struggles many medical providers share.
Above all I have come to characterize the virtuous medical professional as self-aware. One realizes what he or she knows, what motivates him or her, what is expected of him or her, and seeks to continually renew this understanding. Medicine will likely remain a challenging field, requiring providers to balance professional and personal incentives. Taking the journey to find that balance and renew it throughout one’s medical career seems paramount to professional development and wellness. Fundamental principles and core domains provide excellent ideals but open discussion can help illuminate and guide one’s personal journey to incorporate and exemplify those virtues.
Eric J. Keller is a medical student.
