Educating for Professionalism

Eds Delese Wear, Janet Bickel
University of lowa Press
£36.50, pp 215
ISBN 0 87745 7417

The joy of being asked to review a book is that sometimes you end up reading something whose title alone would have convinced you that there were better uses of your time. Jude the Obscure would have approved of the title of this book. Some of the contents are equally woolly. However, there are three chapters that have made me think harder than I have for a long time. “Not difficult in an orthopaedic surgeon,” I hear you say. Well, I challenge anyone involved in medical school curriculum design to read the chapters by Hafferty (“In search of a lost cord”), Martinez (“Ethics of authenticity”), and Coulehan and Williams (“Where have we been? Where are we going?”). If you can then honestly say that you do not need to change your curriculum, then please can you let me know at once, so that I can come and see what you are doing and learn from it. The key questions that these chapters touch on are: “What is professionalism, and can we train and assess in this nebulous but important area?”

Professionalism, in part, seems to involve having a balanced understanding of, and respect for, the needs of your patients, your employer, and your profession. If any one of the three dominates, then unacceptable behaviour can result. As Martinez points out, the behaviour of doctors in Nazi Germany was a result of those doctors allowing the state to be the dominant influence on their behaviour. If respect for the patient's view is the only criterion, then you may end up with doctors who think it is justified to feed their patient's addiction. If professional responsibility swamps the other two, then it could result in a cover up like that which seems to have occurred in Bristol.

When students first start clinical medicine, they will have their own ideas of what they think is right and wrong, and how they think it is appropriate to behave. If they have no opportunity to discuss and resolve the differences between their values and those they perceive are required of them to work as a doctor, there will be two consequences. Firstly, they will start to feel isolated from the community of medicine. They may even become demoralised and find fault with themselves for having values so different from those apparently expected of them. Secondly, the profession itself will miss an important opportunity to be looked at from the outside and challenged on behaviour which is not actually acceptable but which those working in that environment can no longer see.

These three chapters should be the basis of a discussion in your medical school on how you propose to address this problem, both for the benefit of your students and of medicine itself. We in Oxford are certainly going to try.

Christopher Bulstrode, orthopaedic surgeon, Oxford


studentBMJ 2001;09:305-356 September ISSN 0966-6494