Educating physicians: are we doing enough?

The context for the above question is the Spirituality/Medicine Interface Project of this journal, ie, the humanistic aspects of becoming and being a physician. Taking the knowledge and skills aspects of professional competence for granted, I focus in this essay on the person of the physician, ie, professional identity, integrity and responsibility manifested in observable attitudes and values. The Project assumes that religiosity, spirituality and morality are relevant and contributory to the latter. The question is, whether sufficient emphasis has been put on these dimensions of what it is to be a physician, particularly during medical school and residency training. The views expressed are mine, but they incorporate and build on the contributions of many others.

Brief Review of Some Concepts and Premises

The Morality of Medicine

I stipulate that medicine is the humanistic application of scientific and technical knowledge and skill for the benefit of people's health. It is a moral activity because responsibilities and decisions about life, health and death are moral issues. The greater the scientific knowledge and technical skill of physicians, the greater are their moral responsibilities toward individuals and society.

The goals of medicine derive from the fact that suffering sick people need professional care, cure or healing. (1) However, the goals also encompass the prevention of suffering of individuals and communities. (2) The social standing and professional privileges of physicians are historically based on their responsibilities for public health, including responding to the suffering of the population at large in case of epidemics or disasters. (3) I have argued that the goals and morality of medicine encompass both the doctor-patient and the doctor-society relationships. (4)

In this essay, I use the term 'practice of medicine' inclusively to mean all professional activities of physicians aimed at improving people's health, whether through direct patient care, research, public health service, teaching, administration, etc.

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The Functions, Morality and Professional Identity of Physicians

Disease means that the normal physiology of cells/tissues/organs (including the brain) becomes impaired or disordered. Illness and suffering denote the lack of wholeness of the person, and imply the subjective aspects of having a disease. Within the doctor-patient relationship, individual physicians may approach patients' complaints and symptoms differently reflecting different professional moralities and identities. Curing means the elimination, or at least, the containment and control of the disease as a biologic problem. Some physicians' identity may be associated just with this function. Healing is the restoration of the wholeness and integrity of the person who is ill, irrespective whether the disease is cured or not. Seen in a holistic context, healing encompasses the physical, mental, social and spiritual dimensions of patients as persons. Care denotes the attention to the person that may become the default function of physicians when curing the disease, or when healing the person, is not possible. Physicians as healers apply the caring, curing or healing functions according to the given clinical situation.

Within the doctor-society relationship the morally based social responsibilities are carried out both individually and collectively by physicians. These include clinical research, public health and preventive health measures, attention to the possibly harmful social ramifications of the ill health and/or treatment of individual patients, (5) as well as the advocacy for remedies in those aspects of public life and policy that are injurious to the health or aggravate the disease of individual members or particular segments of the population or society at large, such as unjust health care policies. (4) Here, physicians are called to function primarily as teachers and leaders. Thus, the ideal professional and moral identity of the physician is the tripartite healer-teacher-leader. (6)

Spirituality and Religiosity in Medicine

Spirituality has often been confused with religiosity, even though someone may be religious but not spiritual, and the other may be spiritual without being religious. Morality may be affected by either, but may manifest independently as well. Religious beliefs and the healing arts have been closely related throughout human history. There are two sides to this: the physician's and the patient's.

On the physician's side, the nonreligious Hippocratic medical ethic was amended by the major monotheistic religions, and it became a religious moral obligation to act charitably on behalf of the sick. With advancements in the natural sciences, mainstream Western medicine has become a secular scientific discipline and practice, although there are religious orders and a minority of physicians who see medicine as ministry. (7) In these cases religiosity seems to be accompanied by spirituality. (8) On the other end, the reductionistic biologic view emphasizes the scientific cure of diseases, not the healing of or care for patients. Such a disposition is not only secular but lacks spirituality as well.

On the patient's side, reliance on and commitment to religious beliefs has been a double-edged sword in terms of health care decisions and related consequences. Patients who may consider their illness a test of their faith or punishment by God may not see a doctor or comply with treatment recommendations, sometimes with fatal consequences. On the other hand, among those who seek and accept medical help there has been a positive correlation between religious activities and health outcomes. (9-11) Religious faith manifested in religious practices may result in a hopeful, confident and trusting mind-set that has a positive influence on physiology and healthy behaviors, as well as on self-image and relationships with others. This is very important and clinically useful for the physician to know.

Although the latter findings have provided information only on religiosity, not on spirituality, they have been publicized as proof that spirituality is important in medicine. This led to the recommendation that physicians should take a 'spiritual history' to understand patients' religious views and activities. (12) This is an unfortunate confounding of religiosity with spirituality. Asking patients about religion may not necessarily open up the spiritual domains of their lives, because some are not religious yet spirituality is important to them. Thus, it may not create a spiritual domain in the doctor-patient relationship. However, if exploring spirituality would mean an open inquiry into whatever may be important and relevant to patients, particularly in their current predicament, (13) including religion and spirituality, the doctor-patient relationship would be enriched. Indeed, spirituality may be manifest if such inquires conveyed to patients that physicians are open to anything that matters to them as persons, not only their current symptoms or complaints.

That spirituality and religiosity are not the same is well documented. (14,15) In the Oxford Dictionary 'spiritual' connotes sacred, divine, inspired, refined, sensitive, not concerned with the material or with the external reality, etc. Some say that there are as many spiritualities as there are persons. Sulmasy (8) allows for this heterogeneity by defining it as "a description of one's relationship with God" wherein individuals may define and experience both God and the relationship in different ways. My notion has been that it is about something beyond the concrete and tangible, transcending one's own limits or interests or views, being other-directed and outer-connected, and able to see oneself as but a small part of humanity and nature. Our awareness of the latter may be a necessary prerequisite of spirituality. (16)

In my view, when physicians, as healers, prioritize the person instead of the disease in family, social, cultural, religious and spiritual contexts, spirituality may be evident as a component of the moral framework of medicine. And, if physicians were able to transcend the doctor-patient relationship by also considering possible untoward social and medical sequelae of the patient's present illness and/or treatment--such as unintended and unrecognized harm to members of the family and/or community (5)--spirituality may be even more recognizable. The ethical responsibility of physicians in the not-person-specific preventive and public health services may also be considered in this context. In other words, one may recognize spirituality in the physician's 1) selfless and committed patient-centered attitude; 2) effort to understand patients' illnesses in the context of individual personhood and social connectedness, so as to be able to discern their best interests; 3) acceptance of the limits of medicine and of personal abilities; 4) fair consideration of the wider ramifications of medical actions and decisions, and 5) concern for the well-being of the larger human community. (17)

What Kind of Physician?

The above description fits physicians who practice medicine as a secular vocation. The doctor-patient relationship is motivated by service to others. However, it is up to individual physicians to decide what kind of morality will guide their professional activities, ie, whether they practice medicine as a vocation, business, or job. The nature of the underlying doctor-patient and doctor-society relationships is different in these three kinds of dispositions. When medicine is practiced as a job, the employee-client relationship depends on factors and considerations external to it. When medicine is practiced as a business, services are established and prioritized, and certain populations and/or conditions may be targeted, to maximize profitability. The businessman-consumer relationship depends on physicians' financial interests. While in either of these relationships physicians are expected to apply their knowledge and skills competently, conscientiously and ethically, there is little room for spirituality in these kinds of dispositions toward patients and society.

The above characterizations are intended to be descriptive, not judgmental. They are not about the source of income, but about physicians' sense of professional morality manifested in their disposition toward patients and society. Being an employee of a governmental or academic or not-for-profit healthcare institution should not necessarily prevent physicians from practicing medicine as a vocation (ie, as a committed service to others), and calling those who need their services patients not clients. The morality involved depends on whether the emphasis is on convenience and self-interest or on the interests of patients and society, even if personally inconvenient. In the latter, spirituality may be an important ingredient, as it tilts the balance between altruism and self-interest to the former.

Issues of Physician Education

The Institution of Medicine report of 2001 recommends that physician education should emphasize patient-centered care, evidence-based practice, performing integrative tasks within interdisciplinary teams, as well as informatics and new technologies. (18) In its proposed 'ideal medical education system,' the Ad Hoc Committee of Deans (19) amends the above by stressing that to achieve the new goals of medical education physicians have to acquire attributes necessary to meet their professional responsibilities: "knowledge, skills, attitudes, and values." Attitudes and values determine how the knowledge and skills are applied, but they may vary independently of knowledge and skills. (4)

I stipulate that morality is the underpinning of professional identity, integrity and responsibility, and that the ingredients of these attributes come from the ideas and concepts taught, the behaviors/attitudes observed, and the events and predicaments personally experienced. The latter two are key determinants of what kind of professional morality becomes internalized. Thus, I agree with Huddle (20) that professionalism denotes medical morality, not competence, and that its development depends on trainees' exposure and responsiveness to the lived examples of virtuous faculty. Kenny et al (21) emphasize the importance not only of role models but also of the capacity of critical reflection on one's own and the role models' behaviors/attitudes/values, and on the institutional culture. However, since students/residents encounter several role models who may demonstrate different critical reflections if any, the resultant moral enculturation may vary. These processes may go on without conscious awareness. Therefore, a primary educational objective has to be to develop a learning environment of critical reflection.

Coulehan (22) suggests that the current emphasis on professionalism aims at the formation of humanistic physicians, presumably to counteract the dehumanizing health care environment that is "hostile to altruism, compassion, integrity, fidelity, self-effacement, and other traditional qualities." He argues that medical education should explicitly nourish motivation and virtue, and that "becoming a physician involves witnessing, and not just behaving." The latter seems to be emphasized in the current rule-based professionalism, while he advocates the traditional narrative-based professionalism, ie, the lived examples of professional virtues. Coulehan also recognizes the detrimental effect on trainees of the conflict between explicit and tacit learning experiences about value systems, ie, the discrepancy between "what we preach and what we do." (4) He postulates that this leads to one of three kinds of professional identities: technical (includes cynicism), nonreflective (characterized by self-delusion) and compassionate and responsive (able to resist or overcome the above value conflicts).

Cooper and Tauber (23) suggest that medical students lack the opportunity to adequately understand their own emotions and biases. The capacity to be self-reflective and to be guided by values tends to be underdeveloped. These attributes are necessary for genuine patient-centered clinical care, because that requires the recognition of the moral underpinnings of the doctor-patient relationship, and of "the central place of values in clinical decision making."

Medical ethics education is now ubiquitous in U.S. medical schools, but there appear to be notable variations in the curricula, and there is a dichotomy regarding its goal: is it to create more virtuous physicians or to develop skills for recognizing and solving ethical problems? (24) I think the goal should be both. Even though the majority of deans agree with mandatory ethics courses and ethical role modeling by faculty, 20% of schools provide no funds for teaching and 52% for curricular development of ethical issues. (25) This is about leadership responsibilities.

Humanities programs are also ubiquitous and show great variations. Leadership seems most notable at Pennsylvania State University College of Medicine where the Department of Humanities, the first of its kind, has been in existence since the inception of the medical school itself in 1967. (26) The Department provides ethics education as well. Today, its mission is "to reassert the values of the profession in the wake of managed care and its business ethic," among others. There are six doctoral degree professors, and the required courses, conferences and seminars cover all four years of education. The dean considers the Department of Humanities the "heart and soul" of the medical school.

In 2004, 84 of 126 US medical schools offered mostly elective courses in spirituality in medicine, but there are great variations in scope and content, and published reports lack details. (27) Often, spirituality is part of the humanities curriculum. It is not clear how these programs address the spirituality of physicians-to-be and the spiritual aspects of physicians' relationship with patients and society.

Spot Check on Reality

Do these curricula in ethics, humanities or spirituality foster the development of the attitudes and values needed to serve the goals of medicine? Do they offer guidance regarding the social responsibilities of physicians? With some exceptions, the ethics of health care doesn't seem to be featured prominently, if at all. Yet, provision of health care is a major moral issue, and should concern the humanities and spirituality as well. Teaching about the U.S. health care 'system' is important, (28) but if it is about buying into--and thus implying acceptability of--the unjust, neglectful and profit-driven private insurance and managed care policies that result in death and suffering, (4) such teaching denies fundamental medical morality and responsibility. Wolfe (29) asks whether medical schools teach "acquiescence with the destruction of medicine by market forces" (ie, insurance and pharmaceutical companies), or resistance to what is unethical and guide toward constructive change? He introduced courses in research-based activism in some medical schools. Clearly, education of physicians should entail the affirmation of the moral position on the right of everyone to health care. (4) Remaining silent about the unethical status quo of health care severely undermines the integrity of humanistic education, as well as that of individual physicians and the medical profession.

A clinical psychologist friend recently wrote: "Your article (4) rekindled my frustration with health care professions, and particularly SOME physicians. I used to work in a Primary Care Clinic, and some of the physicians stated they were jealous of the amount of time I was afforded to see patients (about two hours) compared with the approximate 30 minutes they could devote. They would often say that they recognized that the quality of care they could provide was being compromised by the number of patients they had to see every day. I often asked, "Are you willing to accept half the salary (that would still be more than I make), if you could see half the number of patients in a day?" These "job/business" oriented physicians were unwilling to accept that compromise. Yes, health care is now a commodity that is directly tied into the profit system. As long as health care providers are willing to compromise quality for the almighty dollar, we are all in trouble." (30)

The professor devotes a clerkship session to discuss the balancing of personal and professional life, ie, "time spent with family versus time spent making money." He explains "that being a physician is what I do, not who I am. I am a husband and father first." (31) This phraseology is troubling. It may not be intended, but it sounds like 'I do and teach the job of the physician to earn a living, but it has nothing to do with my identity,' or 'my job conveniently serves my interests, and it is not about my commitment to serve others.' Of course, it is important to call attention to the nonmaterialistic richness of life, and the commitment to one's spouse and children, but these do not lend special identity. I suggest medical students should hear something like this: "I am a physician, and it is my vocation (ie, deeply felt commitment) to use my knowledge and proclivities to carry out special functions and responsibilities consistent with the goals of medicine in society. I am also a devoted spouse and parent, and conscious of taking care of my own physical and mental health, because without the latter I cannot responsibly fulfill the roles I have assumed." (Note: physicians who function in public health or preclinical research or other nonclinical areas may also identify themselves this way.) Prioritizing the identity, integrity and responsibilities of physicians does not translate into neglect of family or oneself. It does imply, however, that one is ready to be a healer, teacher or leader of individuals, families or the public, when that is called for.

Recommendations

Are we doing enough? I think not. First, the educational environment should contain:

1. Culture of critical reflection--this means openness to self-examination aimed at self-understanding, and reflection on others' observations, attitudes, values and behaviors; it involves everybody: a) individual trainees and their teachers, b) groups of particular sets of trainees and of relevant bodies of educators, c) representatives of other disciplines; the reflective discussion of lived experiences becomes an integral part of professional formation as a modus operandi.

2. Positive role models--who demonstrate and discuss how to deal with the conflicting value systems (ie, the discrepancy between what is taught and practiced), so that integrity and other virtues may be internalized.

3. Narrative-based professional education that provides examples of witnessing professional identity, integrity and responsibility, and thus conveys that medical morality is the essence of physicians' professionalism.

Second, the content of education should entail the professing of the following:

1. Practice of medicine is a moral activity, in both clinical or nonclinical settings, but the nature of morality depends on whether it is a job, business or vocation.

2. Goals of medicine entail both the individual and the social dimensions of illness and health.

3. Morality is the underpinning of professional identity, integrity and responsibility, as it entails not only ethical decisions and actions but values and virtues as well.

4. Spirituality enriches morality, and facilitates the motivation to practice medicine as a vocation, because it tilts the balance between altruism and self-interest.

5. Physicians have professional responsibilities in both the doctor-patient and the doctor-society relationships, but they also seek the cooperation of other disciplines and stakeholders.

6. Goal of professional formation in medical school is to graduate generic humanistic physicians of integrity and self-respect who see the practice of medicine as a vocation; while in residency the goal is to get physicians ready to be healers-teachers-leaders.

7. Ethics, humanities and spirituality are essential toward the above goals, and are creatively integrated into the curriculum throughout the years of medical school and residency.

8. Interests and values of patients and research participants are prioritized over science and profit.

9. Medical educators, students and residents recognize and confront the injustices, and explicit harm to millions, caused by the current US health care environment.

10. Integrity of professional formation requires the affirmation of the moral position on the right of everyone to equitable health care.

References

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2. Hanson MJ, Callahan D, eds. The goals of medicine: The forgotten issue in health care reform. Washington, DC, Georgetown University Press, 1999.

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5. Solyom AE. Ethics of social responsibility: The foundation of partnership, promotion and prevention. Paper delivered at the World Federation for Mental Health Biennial Congress, Melbourne, Australia, February 2003.

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18. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century/ Committee on Quality Health Care in America, Institute of Medicine. Washington, DC, National Academy Press, 2001.

19. Ad Hoc Committee of Deans. Educating Doctors to Provide High Quality Medical Care. A Vision for Medical Education in the United States. Washington, DC, Association of American Medical Colleges, 2001.

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24. Eckles RE, Meslin EM, Gaffney M, et al. Medical ethics education: where are we? Where should we be going? A review. Acad Med 2005;80:1143-1152.

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26. Hawkins AH, Ballard JO, Hufford DJ. Humanities education at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Acad Med 2003;78:1001-1005.

27. Fortin AH, Barnett KG. Medical school curricula in spirituality and medicine. JAMA 2004;291:2883.

28. Finkel ML, Fein O. Teaching about the changing U.S. health care system: an innovative clerkship. Acad Med 2004;79:179-182.

29. Wolfe SM. The destruction of medicine by market forces: teaching acquiescence or resistance and change? Acad Med 2002;77:5-7.

30. Bolger JP. Personal communication.

31. Kellner KR. Teaching and learning moments: The best CBC ever. Acad Med 2005;80:904.

Antal E. Solyom, MD, PHD, MA

From the University of Virginia Health System, Charlottesville, VA.

Reprint requests to Antal E. Solyom, MD, PhD, MA, the University of Virginia Health System, 3300 Rivermont Avenue, Krise 6, Charlottesville, VA 24503. Email: [e-mail]