The paradox of professionalism education: the context of one U.S. medical school's curricular reform
Maderer, Ann Margaret
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In the past fifty years the medical profession in the United States has been transformed by federal and commercial forces. At teaching hospitals, clinical faculty were pressured to cut costs, treat more patients, and spend less time training students. Evidence emerged that medical students became increasingly cynical and detached throughout their training, and medical educators grew concerned that the for-profit priorities of clinical environments were damaging to the professional identities and values of trainees. Consequently, American medical schools reformed their curricula, adding coursework in bioethics and doctor-patient communication. These measures would not, however, counteract the stubborn effects of the so-called hidden curriculum in medical school. Associated with the unintended and implicit lessons that undermine espoused institutional principles, this “curriculum” was thought to be exacerbated by the challenges of contemporary clinical settings. In the late 1990s the “professionalism movement” arose to further the cause of medical ethics education and to promote more accountability in practice; by 2003 the accrediting body of North American medical schools mandated the explicit teaching of professionalism. Professionalism curricula differed from ethics in that it emphasized observable virtuous attitudes and behaviors rather than cognitive reasoning. The reforms at Tufts University School of Medicine (TUSM) in Boston illustrate one approach to the teaching and assessment of professionalism. Archival materials show that TUSM responded to the accreditation mandates by implementing coursework, special programs, performance-based assessment, and the medical school induction rite, the White Coat Ceremony. Professionalism education was complicated for medical schools like TUSM by a lack of clear curricular and institutional goals. Furthermore, the practice of medicine did not necessarily coincide with the ideals of the profession, and senior physicians were inconsistent role models of such ideals – contradictions not lost on students. In 2013 the medical school accreditation agency revised its standards regarding professionalism, shifting its focus to the context for developing professionalism, the learning environment. Recommendations to medical schools for advancing professionalism education include faculty development programming and preparing students to face the ideological conflicts inherent in the current healthcare system.