In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy confusing problems defy technical solution. The irony of this situation, is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner must chose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and non-rigorous inquiry? Donald Schon, 1987, p.3
Schon was referring to reflective practice, as very nicely described by Clare Morris on the Medical Education Matters blog. But he could just have easily have been talking about medical research or, the subject of this blog, medical ethics education.
A review of ethics curriculae in 2000 concluded that, there is a consensus that the ultimate goal of medical ethics, and indeed of medical education as a whole, is to create ‘good doctors’ (Goldie, 2000).
This surprised me and will probably surprise most medical students. Not only does medical ethics play a relatively small role compared to traditional subjects, but it is still possible in many medical schools to graduate without passing ethics assessments. Even when students do pass it’s relatively easy for a bright student to know what to say irrespective of whether or not they believe it, and even if they do believe it, the links between ethical thought and ethical action are tenuous.
What constitutes a ‘good doctor’ may at first to appear somewhat nebulous, but conceptions have been remarkably consistent. Whitehead studied discourses of the ‘good doctor’ over the last century and described them as a carousel, with different aspects rising and falling in prominence. To take one example, apparently contemporary concerns about the lack of humanity in care were also around in 1927 when Francis Peabody wrote in a keynote to Harvard Medical School,
“The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine – or, to put it bluntly, they are too scientific and do not know how to take care of patients.”
What is required to be a ‘good doctor’ is also context dependent, for example there will be times when technical competence takes precedence over sensitivity or quick decision-making takes precedence over patience.
The most interesting work about what it means to be a ‘good doctor’ is being carried out be Charlotte Rees and Louise Montroux who are studying medical students conceptions and experiences of professional behaviour. Unsurprisingly perhaps, students tend to think about professionalism in terms of individual character and action, rather than more general terms, such the GMC ‘Duties of a Doctor’ or the succinct 2005 Royal College of Physicians definition of professionalism,
A set of values, behaviours, and relationships that underpin the trust the public has in doctors.
The contrast between institutional definitions and medical student experiences of professionalism (and the ‘good doctor’) is perfectly described by Donald Schon’s quote above. An overemphasis on teaching principles has left medical students, professionals and patients sceptical about whether we are serious about helping students and doctors to ‘be good’.
A brief history.
For the first half of the twentieth century there was little or no concern with educating for professionalism- a medical ethics reliant on etiquette and paternalism was assumed because a doctor was ethical by virtue of the being the kind of ‘gentlemen’ that doctors were, and medical ethics was not a subject that could be studied as, “One acquired it in the course of learning to become a good doctor,”
Doctors were assumed to be ‘good eggs’ and that was reason enough to dismiss attempts to introduce anything resembling professionalism/ ethics or communication skills training. The problem with this approach was the rather obvious fact that there had always been ‘bad eggs’. Medical ethics education was slowly introduced in the 80s and 90s, but it’s still possible to graduate at the end of medical school without passing exams in medical ethics. Even if a student passed exams in medical ethics it was highly doubtful that knowledge of ethics translated into ethical action anyway. Among the profession, the problem of scandals involving ‘bad eggs’ in recent years caused such a stink that the laissez-faire approach to professional self-regulation could no longer be tolerated. And so the state stepped in and now we have inspections and regulations, appraisals and revalidation which have demoralised professionals with administrative burdens while doing nothing to improve professionalism or restore public trust.
It has become increasingly obvious that neither medical ethics education, nor professional laissez-faire self-regulation, and certainly not state bureaucratic inspection and regulation are contributing to professional, ‘good’ doctors.
How to become and stay, a professional, good doctor.
The 2010 Royal College of Physicians, Future Physician report said,
We call on all doctors to recognise that medical professionalism in a changing world looks beyond the boundries of medicine. (RCP, 2010)
The first, and most important thing to do is realise that being a professional good doctor more than anything else, is in order to benefit patients and society. According to George Bernard Shaw, ‘all professions are a conspiracy against the laity’, and the medical profession is singled out as ‘a conspiracy to hide its own shortcomings’. This is still a popular belief and can only be addressed if professionalism is conceived, taught and practiced in partnership with patients and the public.
The most important part of partnership is humility. The definition of evidence-based medicine as the integration of scientific evidence with professional expertise and patient values, demonstrates the paternalism that still dominates medical thinking. Missing from this conception are the professional’s own values, the patient’s expertise and the expertise and values of other important stakeholders such as family and carers. Putting our own values into perspective can be achieved by values Based Practice. Narrative medicine teaches us narrative humility, the awareness that patients have not only medical, but also personal histories and the awareness that illnesses fit into the context of real lives. Teaching about epistemic justice reveals that patients have ways of interpreting illness, suffering and medical interventions that are of profound importance.
Awareness that our own, medical perspective is only one of many requires us to engage with voices and opinions we might not come across in our usual practice. Social media offers huge potential because it is here that people using blogs, Facebook, Twitter and so on are writing their own stories about their experience of illness, suffering and overcoming and about healthcare and professional behaviour. Conversations between patients and professionals are challenging and reinforcing conceptions of professionalism, the good doctor and the good medical profession.
Remaining professional and being good in the ‘swampy lowlands’ of clinical practice requires career-long sustenance. Narrative-based supervision combines aspects of narrative medicine and clinical supervision in a form that students and professionals can use to support each-other with the ethical problems they face every day. This gives greater emphasis to the importance of teamwork, shared responsibility and learning, and mutual support that makes participants active in their own professional identity formation. A model of group support that enables staff of all backgrounds and levels to come together and talk about how they are affected by caring for patients, called Schwartz rounds, is already taking place at over 300 English NHS institutions. Both narrative-based supervision and Schwartz rounds allow more senior professionals to take on the role of supervisee, so that in so doing they role-model clinical uncertainty, ethical difficulty and professional vulnerability, in short – humility.
Traditional ethics, based on principles and case-based discussions should not be abandoned. It comprises part of the instructional scaffolding necessary for deeper learning and ethically informed practice. Combining technical expertise with moral sensitivity is the art of medicine known as practical wisdom or phronesis.
Combining medical ethics with practical humility would be a sound basis for training, nurturing and sustaining professional, good doctors now and in the future.
I approach this subject from two standpoints – as an ethicist with a philosophical training and as a human being with experience as a CEO of a charity supporting people in distress. In my experience it is not useful to attempt an all-embracing definition or link between the medical technical and the ‘humane’. Rather it is about the hard work of actually thinking about these issues, discussing them, sharing experience and recognising that the key thing is to achieve (and maintain) the ability to act towards patients in a kind way – moreover one that will pass muster with ones own standards in retrospect and in the opinion of peers.
Yes this has to be addressed during training and indeed CPD. Yes we all act/respond in ways that we come to regret – sometimes because we have new knowledge that ‘if only we had know’ at the time. The saving grace is that apologising has the effect of not only cancelling out the hurt but of forging a new, much stronger bond. The ubiquitous belief that to apologise amounts to gratuitous acceptance of ‘liability’ has long undermined this optimum solution!
There are of course skills to be learned and practised; active listening, eye contact (not looking at the computer screen without explanation and excusing oneself), reflecting back to the patient to demonstrate that one has taken their concerns on board. All with the recognition that these skills are needed for the sake of the patient and the relationship – and are may well not be directly relevant to the technical aspects of the diagnosis and treatment!
Perhaps the best way of appreciating this is through considering exemplar patient experiences and role play. Of course the doctor’s own family and friends have these experiences and they might ‘speak’ more clearly to their priorities simply because they are necessarily aware of the impact that a doctor had that might have been so much better.
I will leave it there!