Training Tomorrow’s Physicians
This time of year, when new doctors arrive to begin residencies under our Medical Staff’s guidance, I’m reminded of the play, “My Fair Malady,” a musical written and, well, produced by some of my medical school classmates.
In this student concoction, two deans argue over whether anyone can be taken from the street and trained as a doctor. True to its Broadway namesake, in which Cockney-to-the-core Eliza Doolittle is transformed into her mentor’s image of a lady, the central character of “My Fair Malady” becomes a physician in the image of his mentor.
Beyond this parody of nature vs. nurture, we here at Stanford have differing images of who our physician Eliza Doolittles should be.
Are we trying to train future faculty of our medical school or other institutions? Do we want to train physicians who will go into the community and deliver needed primary care to physician-short areas? Or are we training superspecialists to deliver their highly sophisticated technological expertise in urban medical centers? Are we training people who are only interested in working in medicine? Or are we interested in training people with joint degrees in business, law or public health who will surely do things with their degree other than take care of patients?
Many of us believe that we are and should be proudly training people for each of these paths. So while our trainees hardly fit a unitary image, I believe there are some universal traits which trainees should bring with them - and which we must nurture throughout their education to ensure their success at whatever job they ultimately take. And these traits don’t center on the lab or even the bedside.
Jordan J. Cohen, M.D., president of the AAMC, wrote in a recent column entitled Minting ‘Good Doctors’ that giving our trainees scientific information and clinical skills to care for their patients is a given. But he says the core of a “Good Doctor” isn’t knowledge or technical skill, but rather, an attribute that goes by many synonyms: character, integrity, honor, moral fiber and professionalism.
With all the threats of commercialism in medicine there is an increased interest and need for physicians to be professionals and place the interests of patients ahead of their self-interest regardless of where they work. Cohen rightly states that this is a “core value of medicine” and that it is the “elemental trust that sustains the doctor-patient relationship.”
But can professionalism be taught? Or rather can it be learned? Are people “hard wired” with solid moral fiber or does it come through their upbringing before they even arrive at medical school? More importantly, can we have any influence to change bad behaviors or character once we take students, interns or residents under our wing? These are all important questions that deserve consideration.
An article in the Dec. 22, 2005, New England Journal of Medicine found that physicians disciplined by state medical boards were three times more likely to have shown unprofessional behavior while in medical school than a control group with no disciplinary records. This research seems to support the growing movement to make professional behavior a requirement for graduation from residency programs.
But what does that mean?
In 1999, when the Accreditation Council for Graduate Medical Education mandated professionalism as one of six “core competencies” required as of this year for graduation, they did so not with platitudes but by pragmatically identifying UNprofessional traits to avoid. These are:
Irresponsibility, such as unreliable attendance at clinics and failing to follow up patient care activities
Diminished capacity for self-improvement, including failure to accept constructive criticism, argumentativeness and display of poor attitude
Immaturity
Poor initiative
Impaired relationships with fellow students, faculty, nurses or patients
Significantly, all of these factors were stronger indicators of future disciplinary action than test scores or grades. Therefore, the evidence indicates that screening for appropriate character traits as part of the medical school admissions process seems to be the first step in being able to train “Good Doctors.”
But the process doesn’t stop there. We need to apply the same criteria when we choose interns and residents. Applicants for housestaff positions must embody virtues such as altruism, honesty, empathy for those in pain, fervor for social justice, and commitment to self sacrifice. These are the “building blocks” of the road to professional conduct. Clearly our programs must look beyond the necessary grades, board scores and research productivity to select applicants with the requisite personal characteristics.
But selecting the right candidates doesn’t let us off the hook in terms of helping our trainees become professionals. As medical staff members we must nurture our trainees’ journey to professionalism by ourselves modeling behaviors and character traits that we want our students, interns and residents to incorporate into their lives as physicians. And we must actively teach our trainees by correcting - in “real time” whenever possible - behavior we observe or learn of which we know to be unprofessional.
Why should we care so much?
Doing our job is a given, but there is more. All of us become patients some day, and that’s when we will learn first hand the value of respect, compassion and professionalism from our caregivers. (For that matter we also need to find professionalism in those doctors working in the corporate or governmental suites who decide which procedures to authorize, which rules to apply.)
We need to do our part to see that the physicians we train exemplify the character, moral fiber, integrity and professionalism that we all want from our own doctors - regardless of what tasks they will be performing in the years to come. In the end, they are all physicians.
