[الدكتور أحمد باذيب]

Providing Experiences

Until the late 1970s, the formal teaching of ethics, professionalism, and humanism was not part of the medical school curriculum.13 Since then, educators have developed innovative curricular experiences to expose students to issues of professionalism and promote knowledge of ethical principles,14 skills of moral reasoning,15 and the development of humanistic attitudes. One of the primary goals of problem-based learning (a group-learning process characterized by the shared creation of goals and the pursuit of knowledge) is the development of teamwork and leadership skills,16 attributes central to professionalism. Most medical schools now require students to take a formal ethics course.14 Courses on managing the doctor–patient relationship17 generally include sessions in which students reflect on their experiences with patients and their developing professional persona. Obtaining experience in underserved communities and international settings often helps students understand the social role of physicians.18,19 Although the face validity of such approaches is high, the effectiveness of these additions to the curriculum has not been formally tested.

Potentially more important than these formal elements of the curriculum are the informal experiences of medical students and residents.1,2 A study of primary-school education was the first to label this sort of experience as part of the "hidden curriculum" — "the curriculum of rules, regulations and routines, of things teachers and students must learn if they are to make their way with minimum pain in the social institution called the school."20 In the context of medical student education, the hidden curriculum of rules, regulations, and routines is transmitted mostly by residents (rather than faculty) in clinic hallways and the hospital, often late at night, when residents and students are on call.21,22

Teaching in the hidden curriculum happens through role modeling and the telling of parables as well as through the framework of the educational environment itself. Faculty often perceive themselves as role models for students and claim that this is one of the primary means through which they teach professionalism. But a role model is "someone who, in the performance of a role, is taken as a model by others."23 Role modeling is in the eye of the beholder — the student, not the teacher. "Individuals who are seen as mentors may not realize that they are teaching professional values, and those not seen as mentors may believe that they are."24

Educators now believe that the act of role modeling is insufficient.24,25,26 Role modeling must be combined with reflection on the action27,28 to truly teach professionalism. Attending physicians are not presumptuous enough to believe that if they simply prescribe the correct medication to a patient and leave the room without discussion that the students who are observing will learn to treat the disease. Similarly, modeling professional behavior on the part of a teacher (e.g., showing compassion to a dying patient or offering reassurance about recovery) without following up with discussion constitutes a missed opportunity for teaching professionalism.

Parables are a powerful means of transmission of cultural values; the norms of professional behavior have been handed down through generations of doctors using stories with meaning.29,30,31 In medicine, parables often start with "I had this great case" or "When I was an intern."32 What ensues is a story about a fascinating medical case with a moral about what it means to be a doctor. The published writings of William Carlos Williams, Jerome Groopman, Atul Gawande, and others take this process to its highest form. But these stories are exchanged every day in conversations over lunch, in the hallways, and outside the hospital — a story about how a patient survived when perhaps he should not have, a story about how you would have missed the diagnosis had you not stopped to ask one more question, a story about an observation from a nurse that alerted you to an unexpected problem. These stories not only serve to transmit professional values but also reveal the struggle of how we try (and sometimes fail) to meet the highest standards of professional conduct.33 The tradition of storytelling is instructive for students, but building it into a formal curriculum is a challenge.

The health care environment itself can also have a pervasive effect on professional values. Perhaps some readers remember when patients' charts hung from the foot of the bed. In a world governed by the Health Insurance Portability and Accountability Act of 1996 and the computerized medical record, patient information is revealed only behind closed doors in a double-password–protected patient information system in which an advance warning tells you that all access is being tracked. Although there is ample reason for concern about confidentiality in a world where almost anyone's personal health information is only a few mouse-clicks away,34 the environment itself actually does much of the teaching. An environment with high patient volumes and low staff-to-patient ratios has been shown to foster an attitude among residents that their job is to "get rid of patients."35 Recent changes in residents' duty hours may have both positive and negative consequences for professional behavior.36 For example, limiting duty hours may give residents time to take better care of themselves but may also limit the development of a trusting relationship with patients.