“How did we get here?”

 

I ask myself this every so often, whether it be after hearing a patient’s account of a negative experience with another clinician or trying to advocate for myself or a family member in a healthcare setting. 

 

How many of you out there get excited about going to see your PCP, gastroenterologist, neurologist, opthamologist, surgeon, or even your physical therapist? 

 

How many of you leave each appointment feeling genuinely seen and heard and feeling empowered and optimistic? 

 

I am going to venture to say that those who said yes to these questions are, unfortunately, in the minority. 

 

This stinks.

 

I know that those of us who enter the medical field in any capacity, likely did so because we wanted to serve others and because we enjoy seeing others feel good on account of something we did or helped them do. 

 

So, how is it that so few of us get to serve people in the ways we imagined we would? What the heck happened between entering medical, nursing, physical therapy, or other health professions programs  and graduating with our licenses to start practicing?

 

 

I recently finished reading Afflicted: How Vulnerability Can Heal Medical Education and Practice, by Nicole Piemonte, and these questions, which I likely always had beneath the surface, began to rise within me with a vengeance. 

 

Though she sets out (and I would argue nails it) to answer these questions as they pertain to medical education in particular, I am going to make the argument that what she has found and what she is advocating for is very much applicable to physical therapy, athletic training, psychology, and any other setting that involves patient care. 

 

DISCLAIMER: There is, indeed, no way that I could do this book justice in one blog post, and I would HIGHLY recommend any living human to read it. What I am going to do is dive into one particularly poignant concept, as I feel it has the potential to be quite influential in clinical education, and therefore, in the way we care for our patients in the future. 

 

Let me start with a few questions…

 

 

What does professionalism mean to you?

 

What types of attributes does a true professional have?

 

What does it mean to act  “professionally”?

 

 

 

Evolution of ideas is great and necessary for growth, but not so much when it has evolved into something that is potentially harmful for those whom we serve and care for. 

 

Let me explain…

 

Professionalism education (referring to formal medical school) has been around a loooong time, but it appears to have been reduced to “observable behaviors” that can be crossed off of a checklist¹. This means of educating glosses over the budding clinician as a human being and forces the individual to emerge from medical school conforming to cultural “norms” and exhibiting idealized skills.

 

In other words, students may be learning ways to act or behave professionally without really reflecting on anything about who they are as people.

 

 

Let’s take a step back and look at some of the background information and proposed shortcomings of traditional professionalism education.

 

 

In 2010 the Carnegie Foundation Report stated that professional identity formation should be a focus  in medical education. However, professional identity formation “must be congruent with personal identity.” Put another way, medical education (and the socialization that occurs along with it) should “effectively guide identity formation” as students and residents are “continuously organizing their experiences into a meaningful whole that incorporates their personal, public and professional selves.” This approach to professional identity formation was novel. 

 

 

Cruess et al. highlight stages of identity formation within medical training. Here are some major takeaways⁵: 

• Individuals enter medical school in late adolescence/early adulthood (they are so young!). Generally speaking, they prefer to follow rules and self-reflection is minimal.
• There is significant socialization that occurs through the phases of medical school (med student, resident, attending, practicing physician), and this is where much of the potentially negative “implicit” professionalism training occurs (through role models, mentors, experience, and reflection (or lack thereof).
• Through these stages, and with the objective demands and “competencies” of medical school, many individuals experience some “repression” of their existing identity and therefore some “identity dissonance,” as aspects of their new identity conflict with their old identity. 
• During school, the individual moves from “legitimate peripheral participation” (aka the lay public) to full participation in the medical “community of practice.” In order to fully participate in this community, one must acquire the identity of the community. This can result in acceptance or partial or total rejection of said identity (as the “identity dissonance” implies).

 

This acceptance of identity often parallels an unconscious, but heavy influence of the hidden curriculum⁴ (discussion for another day, but GREAT resource on it HERE)

 

 

 

They are “taught” to distance themselves from patients and to focus on observable, objective measures that they can address and treat.

 

 

 

So, while there might be students with tons of medical knowledge who will do really well on their medical licensing exams, they may not have developed personally and professionally in the way that is required for compassionate patient care. Ultimately, they might have poor patient interactions and offer less quality care down the road.

 

I will also add that this is not unique to formal medical education…

 

In the most recent publication of the Journal of Humanities and Rehabilitation, a research team of clinicians contributed a powerful review of their 10 year research journey (and resultant book) entitled: Exploring Excellence: Author Reflections on Educating Physical Therapists. 

 

Using the Carnegie Foundation’s Preparation for the Professions Program (PPP) as inspiration, the authors conducted their own study of physical therapy (PT) education from the initial entry into PT school through post-professional residency education. The following findings appear to echo the sentiments of the medical education referenced above:

 

• “...there was a strong and visible focus on developing professional identity as experienced through rituals such as white coat ceremonies, among others. The intentional development of professional formation, however-- which requires stronger and recurrent curricular emphasis on teaching for moral professional purpose and commitment-- was lacking.”
• “We see the integration of the humanities into professional education as an essential component for preparing adaptive learners who can navigate uncertain situations in complex systems, act as advocates and moral agents, and demonstrate the moral courage to address societal needs, call out and seek to change substandard practice, and meet our professional obligations.” 

QUICK TIME OUT: This is a fairly dark picture being painted here, I know. However, I believe it is necessary to bring some of this to the surface, because there has been a demand for more from medicine/clinical care for a while, a demand for an answer to the question: “Why can’t all clinicians be damn good clinicians and also damn good humans?” Communication skills and the ability to connect on a human level are just as important as technical skill. 

 

 

There is, however, some good news when it comes to professionalism in healthcare. Turns out, there are things we can do to shift the culture of professionalism among students and clinicians: 

 

1. Dedicated, intentional pauses in daily activities must be created to allow clinicians and trainees to reflect on the meaning (and inherent difficulties) of their work. (Wear, et al.)
2. Reflection on individual experiences with role models and mentors as well as on clinical  and nonclinical experiences during medical education is fundamental to positive socialization⁵.
3. Educators can make identity formation an educational goal and create an inclusionary, healthy learning environment for students.
4. Admissions criteria can be changed and aligned more with identity formation--in other words, schools can interview and select students who already possess characteristics of professionalism. 

 

 

And I’ll just leave this last one right here for you…

 

“Learning to become more comfortable with ambiguity and complexity, whether related to identities specifically or to the practice of medicine more generally, is a difficult endeavor. Yet giving medical students the opportunity to think and write reflectively about their personal experiences may open up the space for them to succeed in this endeavor, especially when it may be the only real opportunity they have to do so in a professional and academic world so defined by the discursive regime of modern medicine.”

My hope is that similar questions begin to arise and spark a fire within you to learn more about this and to see how and where you can start to make strides towards a global shift in our standard of care for patients, as well as in how we are nurturing and preparing our future caregivers and healers. 

 

Thank you for reading 💚

And a SPECIAL thank you to Nicole Piemonte for not only writing an incredible book, but for leading by example and truly walking the walk by way of integrating the humanities in to medical education. You rule. 

 

 

 

References

1. Piemonte, N.M. (2018). Afflicted: How Vulnerability Can Heal Medical Education and Practice. Cambridge: The MIT Press.

2. Brightwell A, Grant J. Competency-based training: who benefits? Postgrad Med J. 2013 Feb;89(1048):107-10. Doi: 10.1136/postgradmedj-2012-130881. Epub 2012 Sep 27. Review. PubMed PMID: 23019588.

3. Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010 Feb;85(2):220-7. doi: 10.1097/ACM.0b013e3181c88449. PubMed PMID: 20107346.

4. Mahood SC. Medical education: Beware the hidden curriculum. Can Fam Physician. 2011 Sep;57(9):983-5. PubMed PMID: 21918135; PubMed Central PMCID: PMC3173411.

5. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015 Jun;90(6):718-25. doi: 10.1097/ACM.0000000000000700. PubMed PMID: 25785682.