Who Am I and Why Am I Here? Professionalism Research Through the Eyes of a Medical Student*

My second year of medical school, someone broke into our student services office. The target was a room full of files containing tests and answers from the last several years. The would-be thief got into the test room by climbing onto a bookshelf, removing a ceiling tile, climbing over a wall, only to be thwarted by a locked file cabinet. The break-in raised some tough questions. Why would a student risk so much for answers to one midterm? How could someone reconcile this with the principles of the profession we are all entering? I would guess that all medical students can empathize with the worry that, no matter how much we have studied, it is simply not enough. Ideally, a higher level of moral reasoning would be involved such that the temptation to cheat would be averted, not by fear of consequences, but out of the sense that to do so would violate one’s sense of integrity, a thing far more valuable than any test grade. Yet, most professionalism curricula do little to enhance moral reasoning and the sense of identity on which it is built. I will review some research on professionalism from this year’s RIME conference through the lens of developing the professional identity of medical students. Professionalism education in medical school spends a great deal of time on what we do, but often fails to consider who we are as developing doctors. Identity, while less malleable, seems far more likely to determine how we will act behind closed doors when we are tired, frustrated, and overworked. It is also shaped by the hidden curriculum. In this year’s conference Reddy et al1 examined how students’ participation in, and perception of, unprofessional behavior changed in the first semester of clinical clerkships. They used a 27-item, yes/no survey, asking students to report whether they had observed a behavior, participated in it, and considered it unprofessional. The study found a significant increase in observation of 21 of these behaviors and participation in 17. Students’ perceptions of a behavior as unprofessional tended to decline as participation in that behavior increased, and students voiced concerns that faculty were not living up to the standards that they taught. This study provides some interesting insights into student behavior. Students resolved dissonance between their actions and professional standards by reframing those behaviors as within the bounds of professionalism. I was intrigued by one particular survey item, “making fun of patients, peers, or physicians.” Each of these three behaviors raises distinct issues regarding the development of a professional identity. I struggle to believe that after five semesters there are any students who have never laughed at a classmate. While mean-spirited mocking is clearly unprofessional, the mild teasing and inside jokes that pass between classmates are often a healthy mechanism for dealing with the stress, mistakes, and awkward moments that are inherent to our experience. Development of such relationships and coping mechanisms is an essential step in professional and personal development. During the clinical years, attending physicians are essentially our bosses. Is there anyone who has never made fun of his/her boss? Making some fun of people who exercise that level of power over us is often a necessary and healthy coping mechanism. Furthermore, the ability to find humor in an emotionally demanding field is essential to preventing depression and burnout. Making fun of patients is a more troubling issue. While most students will readily acknowledge that it is not appropriate, it is also a behavior that all too often we see modeled by residents and attendings. We are left with the choice between being “part of the team,” and upholding principle. Furthermore, we begin to view ourselves as part of the medical community by emulating the doctors who supervise and teach us. Reddy and her colleagues document an alarming, but not unexpected, increase in unprofessional behavior over the course of the third year. I would like to see future investigators consider how these behaviors contribute to the construction of a professional identity, the rationales behind such behaviors, and the competing values involved. Ginsburg and colleagues2 address some of these issues in their paper, “Reasoning when it counts: Students’ rationales for action on a professionalism exam.” Fourth-year students watched videotaped scenarios or read analogous vignettes detailing professional challenges. In a simulated written exam setting, students were then asked what they would do, why, and what would happen next if they did so. The study found that the exam setting led to increased reference to avowed principles and implications, decreased reference to unavowed principles and affect, and no change in reference to unavowed or disavowed implications. In other words, students know what we are “supposed” to say, do, and think when faced with challenges to professionalism and can reproduce it for an exam. In a less formal setting, we are willing to admit that principles such as teamwork and education impact our decisions as well. We also seem to have absorbed that it is never appropriate to consider implications of our actions to ourselves. I appreciate this study’s acknowledgement of the importance of the “why,” as the ability to balance competing values lies at the heart of professionalism. There is often tension between good patient care (spending more time with a patient, always seeking supervision, collaborating with other students) and pressure to achieve good grades (by showing independence, studying for exams, appearing “a cut above” the average student). While we know that professional principles should trump grades, we also know that grades, particularly in our intended specialty, are heavily weighed in the residency application process and that instead of making us more competitive, “good” decisions may actually harm us. I find it troubling, however, that both the subjects of this study and the study itself believe that any consideration of the implications of our actions for ourselves is unprofessional. This puts professionalism in direct conflict with self-care. After all, if a physician always prioritizes patient over self, then he would always choose to stay late to see another patient or talk to a family with no regard for the toll this might take on his own family. She would always read the latest medical literature, never the latest novel. There is little guidance as students attempt to negotiate the balance between altruism and care for self and family. To discourage students from even considering how decisions affect them is to actively encourage a lack of self-knowledge and self-awareness. It makes the desire for health and balance, both necessary if one is to provide excellent care for decades, a disavowed secret that should be carefully guarded. While we should not leave the principles of professionalism behind the second we take off our white coat, we neither can nor should check our selves at the door when we enter the clinic. I hope that medical education researchers will consider the role that identity plays in professional decision making. If we can better nurture students in the formation of an identity that espouses balance, compassion, justice, and excellence, professionalism will be the natural result. If, however, we limit ourselves to focus on dos and don’ts, I have little confidence that we will, in the process, produce physicians who live the values that we preach.