The task of medical education is to “shape the novice into the effective practitioner of medicine, to give him the best available knowledge and skills, and to provide him with a professional identity so that he comes to think, act, and feel like a physician.”1 (p. 5)

During the past few decades, it has become apparent that the issue of the professionalism of individual physicians and of the medical profession must be addressed explicitly at all levels of medical education. For this reason, the subjects of professionalism and professional identity are being addressed directly throughout the continuum of medical education.2–10 As is true of any significant topic that must be learned, there is a defined body of knowledge called the cognitive base that serves as the basis of the teaching, learning, and assessment of the subject. The purpose of this chapter is to outline the cognitive base that should underpin educational activities designed to support learners in medicine as they become professionals and acquire their professional identities.

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 major initiatives throughout medical education aimed at ensuring that physicians both understand the nature of contemporary medical professionalism and live according to its precepts – that they come to “think, act, and feel like a physician.”1–6 As a result, there is now a substantial literature describing how this can best be accomplished, with a recent shift in emphasis toward supporting professional identity formation.

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 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 that are the foundation of the profession would be automatically acquired during the educational process as students “acquire the complex ensemble of analytic thinking, skillful practice, and wise judgment.”

When the first edition of Teaching Medical Professionalism1 was published, considerable experience on teaching and assessing professionalism had been developed in medicine's educational establishments. The book was therefore based upon a body of knowledge that existed, and the authors formed their recommendations upon their own experiences and that of others working in the field. The emphasis has recently shifted from teaching professionalism to supporting professional identity formation,2–4 despite a lack of literature outlining how professional identity formation can be supported throughout the continuum of medical education. It is our hope that this book can partially fill the void, as it brings together educators and researchers who have focused on the subject of professional identity formation in medicine.

The idea that physicians actually have a professional identity is not new. In 1957, Merton published one of the first studies of the sociology of medical education.5 In the introduction to the book, Merton stated (p. 5) that medical education has a dual purpose: “to shape the novice into the effective practitioner of medicine, to give him the best available knowledge and skills, and to provide him with a professional identity so that he comes to think, act, and feel like a physician.”5 Through the ages, great emphasis has been placed on ensuring that medical graduates possess the requisite knowledge and skills, using increasingly sophisticated methods of teaching and assessment.6

Until recently, it was assumed that medical students and residents would acquire their professional identities by patterning their behavior after respected role models.7 The desired identities were encompassed in the concept of professionalism, and physicians were expected to behave like professionals. While there were frequent references in the literature to professionalism, it was not addressed explicitly, being mainly taught in the informal curriculum.

There is agreement that this historic system functioned reasonably well, as long as a homogeneous medical profession that was largely male and made up of members of the dominant social group served a comparably homogeneous population.7 There was also general agreement between medicine and society on shared values. The world changed after World War II. As the medical profession and the society that it served became wonderfully diverse, passing on the traditional values cherished by both the profession and society became more difficult. This was occurring as medicine and systems of healthcare delivery became more complex.

When the first edition of this book was written, there was a substantial body of information in the literature on how to design and implement programs to teach professionalism at the undergraduate and postgraduate levels. It was possible to elaborate a set of principles on the subject based on both our experience and that of others.1–3 As we transition to recommending the addition of supporting professional identity formation as the educational objective, equivalent experience is not reflected in the medical literature. Any principles designed to assist individuals in establishing such programs must be derived from the literature on identity formation outside of medicine,4,5 from the thoughts and recommendations of those who have studied professional identity formation in physicians,6–11 and from the recommendations of authors who have contributed to this book.

As is emphasized repeatedly in this book, the experience gained in teaching professionalism has been enormously valuable and provides a foundation upon which educational programs on professional identity formation can be built. While some of the principles elaborated to help design programs of teaching professionalism are still useful, new principles are required for new educational objectives.

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 physicians.12 When the teaching of professionalism was the educational objective, there was no unanimity of opinion on how best to organize the teaching, with two schools of thought being predominant. Those who emphasized the need for detailed knowledge of the subject tended to stress formal instruction, making the nature of professionalism explicit.13–15 They defined professionalism, listed its attributes, emphasized the role of trust, and stressed its importance to medicine's relationship to society. Others believed that the teaching of professionalism should be approached primarily as a moral endeavor, emphasizing altruism and service, stressing the importance of role modeling, efforts to promote self-awareness, community service, and other methods of acquiring experiential knowledge.

While it would be wrong to overemphasize the differences between these two approaches, they did exist. Establishing professional identity formation as the educational goal quite effectively brings the two groups together. As medicine is a community of practice that students and residents wish to join (see Chapters 1 and 5), the values and norms of the community must be widely known and communicated to learners.

ATTRIBUTES OF THE HEALER

Caring and compassion: a sympathetic consciousness of another's distress together with a desire to alleviate it.

Insight: self-awareness; the ability to recognize and understand one's actions, motivations, and emotions.

Openness: willingness to hear, accept, and deal with the views of others without reserve or pretense.

Respect for the healing function: the ability to recognize, elicit, and foster the power to heal inherent in each patient.

Respect for patient dignity and autonomy: the commitment to respect and ensure subjective well-being and sense of worth in others and recognize the patient's personal freedom of choice and right to participate fully in his/her care.

Presence: to be fully present for a patient without distraction and to fully support and accompany the patient throughout care.

ATTRIBUTES OF BOTH THE HEALER AND THE PROFESSIONAL

Competence: to master and keep current the knowledge and skills relevant to medical practice.

Commitment: being obligated or emotionally impelled to act in the best interest of the patient; a pledge given by way of the Hippocratic Oath or its modern equivalent.

Confidentiality: to not divulge patient information without just cause.

Autonomy: the physician's freedom to make independent decisions in the best interest of the patients and for the good of society.

Altruism: the unselfish regard for, or devotion to, the welfare of others; placing the needs of the patient before one's self-interest.

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.

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.