Lessons in Professionalism 101

A couple of years ago there was an online flap over a MedPage Today blog post about a group of medical students and a vending machine that dispensed beer.

Writer Charles Bankhead was attending a cardiology conference and was on his way to a breakfast meeting when he encountered the young doctors-in-training gathered enthusiastically around the beer machine. He writes:

As they drained the cans and vowed to return often to worship at this altar, something told me this wasn’t the first time they had consumed beer before breakfast.

And then a thought occurred to me. One day I might have to entrust my heart to the care of these young men.

I found the thought unsettling.

He goes on to muse about medical students these days and their behavior, both bad and good, and winds up with some uplifting observations about the medical trainees who helped staff street-corner clinics in New Orleans, ministering to the many needs in the days and weeks after Hurricane Katrina.

“I hope I can remind myself of that the next time I see a group of young doctors gathered around a beer machine,” he concludes.

Students have rarely been known for maturity or prim behavior, but when it comes to medical students, should there be a higher standard?

Bankhead’s blog entry was reposted at Kevin, MD, where the reaction was decidedly mixed. What’s the big deal? wondered several commenters. One person’s assessment: “Honestly, if you get heart palpitations from the idea of late 20s male doctors finding the idea of a beer dispenser awesome, I don’t want you as my patient any more than you want me as your doctor.”

Not so fast, cautioned another commenter, who observed that “it has been my experience that this type of ‘childish’ behavior (getting excited about a beer machine and drinking DURING a conference) generally does spill over into practice.” These are the future doctors who make fun of patients, ogle the nurses and talk more about their extracurricular activities than the business at hand, the commenter wrote.

So who’s right?

As medical students head back to school this fall and the new crop of residents that began training in July gains some seasoning, it’s an opportune time to consider one of the more intangible lessons of medical school: teaching students how to be professional.

There doesn’t seem to be any formal curriculum for Professionalism 101. Yet it would be hard to find a U.S. medical school that doesn’t value professionalism or create expectations for how students should conduct themselves around each other, the staff and their future patients.

A paper published in 2010 in the International Journal of Medical Education attempted to pin down the teaching of professionalism. Is it shaped by medical school coursework? By being selective about who gains entrance to medical school? By strong role models on the faculty?

The researchers reviewed about three dozen previously published studies and came up with some interesting findings. One of the things that seemed to matter most was the learning environment – whether it was supportive and whether students had a variety of opportunities to gain experience and insight into what it means to practice professionally. The researchers found it was also important to have faculty and staff who set a positive example.

There’s been some debate over the role of the medical school admissions process in selecting students with the right qualities. But as the authors of the review note, it can be difficult to determine at the outset of a medical student’s career whether he or she is capable of learning professionalism. Furthermore, there don’t seem to be any reliable tools for identifying candidates who might not measure up.

Finally, assessment and feedback mattered. The researchers wrote that it’s especially important to monitor medical students for unprofessional or disruptive behavior and to have policies for dealing with problem behavior.

Judging from the online discussions at some of the student doctor forums, most medical students are keenly aware of the professional expectations placed upon them. A student who was ticketed for illegally netting crabs at the seashore fretted that the infraction might result in a rejected application for a residency training program. Some students had bigger problems: a DWI arrest, an assault charge, poor academic performance.

We expect a lot of doctors; perhaps we expect too much. Should a certain amount of partying or immature behavior be acceptable among medical students? Or should even an indiscreet Facebook post be grounds for disciplinary action? Some years back I had a conversation with a medical school instructor who spoke of the challenge of curing young medical students of casual terminology such as the word “butt.” Professionalism seems to be a many-layered creature that extends to language and demeanor, especially around patients, yet it’s not always easy to know where (and when) the line should be drawn.

Here’s a bit of evidence, though, that students who grasp the concept of professionalism might also be better able to practice it: In a study that appeared a few years ago in the New England Journal of Medicine, researchers found that doctors who were disciplined by the state medical board often showed warning signs of problem behavior back in medical school. Indeed, problem behavior in medical school was among the strongest risk factors for disciplinary action later in the physician’s career. Other studies, though, have found only a weak association between medical school behavior and future professionalism.

It points to a need for defining more clearly what is meant, exactly, by medical professionalism. Most future doctors do in fact measure up; it’s a minority who don’t, and a reason why the public has some stake too in the education that helps shape medical students into good doctors.

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