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As physicians, patients, and members of the general public have come to believe that medicine's professionalism is under threat, virtually all have concluded that any action to address the issue must include a major educational initiative aimed at ensuring that physicians both understand the nature of contemporary medical professionalism and live according to its precepts. As a result, there is now a substantial literature containing a variety of opinions as to how this can be best accomplished. One of the common themes that has emerged is that the approaches of the past are no longer sufficient.
For centuries, professionalism as a subject was not addressed directly. There were no courses on professionalism and it was not included in the standard medical curriculum. This is not because it was deemed unimportant. The Hippocratic Oath, subsequent codes of ethics, and a host of writers including Osler addressed the values and beliefs of the medical profession, often linking them to the word professionalism. However, it was assumed that these values and beliefs, which are the foundation of the profession, would be acquired during the process of socialization of students as they “acquire the complex ensemble of analytic thinking, skillful practice, and wise judgment.” The learning of professionalism depended heavily upon role models where students, residents, and indeed practicing physicians patterned their behavior on “individuals admired for their ways of being and acting as professionals.” While this method remains essential and powerful, by itself it is no longer felt to be adequate.
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
This book is about education. While the subject is about teaching and learning professionalism, the authors discuss how best to educate the physicians of the future who will be responsible for much of the health and well-being of their fellow citizens. While medical education often appears to have developed in isolation from the formal world of pedagogy, medical students are adult learners and the science of cognition applies to them as it does to other learners. Through the centuries, we have come to understand a great deal about education, but there is still much that we do not know and probably will never fully comprehend. For a period of time, both general and medical education placed great emphasis on the acquisition of knowledge and skills. In our knowledge-based world, this is certainly appropriate, as one cannot function without a minimal level of knowledge. However, recent times have seen a return to an earlier belief that education represents more than facts and figures. It has been said that education is what remains after what has been learned has been forgotten. Michael Polanyi, that wonderful combination of chemist and philosopher, coined the term “tacit knowledge” to help us understand this phenomenon. He stated that “one knows things which one cannot tell.” Tacit knowledge is acquired through experiencing a broad spectrum of life's challenges.
Until recent years, the subject of professionalism was not addressed formally in the medical curriculum. Students became professionals without being aware of it, with the assumption being that they patterned their behavior on that of respected role models. It was only when both society and the profession came to believe that medicine's professionalism had been eroded by forces arising both inside and outside of the medical profession that it was deemed necessary to teach professionalism as a distinct subject, something that is now required by accrediting and certifying bodies. Without question professionalism can be taught and learned in many different educational settings, using a variety of pedagogic tools and methods. However, as faculties of medicine have gained experience in teaching professionalism, common threads have emerged. It has become possible to outline a series of principles that can guide the actions of those designing, implementing, and administering programs aimed at promoting the acquisition of knowledge about professionalism and the behaviors characteristic of a professional. It is the goal of this chapter to outline these principles.
Any set of principles must be compatible with the complex nature of the medical curriculum through which individuals become transformed from members of the lay public into skilled professionals. There has not always been unanimity of opinion on how best to organize the teaching of professionalism. In part, this relates to individual and institutional approaches to the issue, with two schools of thought being predominant.
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