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Read “Medical Professionalism: What the Study of Literature Can Contribute to the Conversation” from Philosophy, Ethics & Humanities in Medicine Although this article primarily explores the use of literature in medical professional education, the same principles apply to students learning about professional, ethical leadership in health care. As you read the article, contemplate how literature can help you develop your own brand of ethical leadership within the health care regulatory environment. Due Thursday Write a 175- to 265-word response to the following: Review Fig.1 on p. 6 of the “Medical Professionalism” article. Select two to three outcomes that are important to you (or that you want to achieve in your professional career) and explain what you are doing (or are going to do) to develop those abilities. Research and identify 2 to 3 books or articles you believe health care administration professionals should read to help improve their approach to health care oversight.
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Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
DOI 10.1186/s13010-015-0030-0
REVIEW
Open Access
Medical professionalism: what the study of
literature can contribute to the conversation
Johanna Shapiro1*, Lois L. Nixon2, Stephen E. Wear3 and David J. Doukas4
Abstract
Medical school curricula, although traditionally and historically dominated by science, have generally accepted,
appreciated, and welcomed the inclusion of literature over the past several decades. Recent concerns about medical
professional formation have led to discussions about the specific role and contribution of literature and stories. In this
article, we demonstrate how professionalism and the study of literature can be brought into relationship through
critical and interrogative interactions based in the literary skill of close reading. Literature in medicine can question the
meaning of “professionalism” itself (as well as its virtues), thereby resisting standardization in favor of diversity method
and of outcome. Literature can also actively engage learners with questions about the human condition, providing a
larger context within which to consider professional identity formation. Our fundamental contention is that, within a
medical education framework, literature is highly suited to assist learners in questioning conventional thinking and
assumptions about various dimensions of professionalism.
Keywords: Medical professionalism, Professional identity formation, Literature, Health humanities, Medical humanities
Introduction
Over the past fifty years the study of literature has become a generally accepted aspect of medical education.
As thoughtful scholars have recently considered how to
teach professionalism effectively and meaningfully, questions have arisen about the role of stories, essays, firstperson narratives, and poetry in facilitating the professional
identity formation of medical students. Those who argue
affirmatively imply that exposing students to literature will
inculcate professionalism virtues and attributes [1]. Those
who disagree assert that the study of literature has goals
and purposes unrelated to professionalism [2]. In this article, we investigate definitions of medical professionalism,
and frame its inclusion in the competency framework as an
effort to anchor its abstract virtues in behavioral specificity.
Next we consider how literature can advance our understanding of medical professionalism through a different
kind of singularity grounded in the literary method of close
reading. Ultimately, we contend that the development of
medical professionalism will benefit from the critical and
interrogative methods of literature.
* Correspondence: [email protected]
1
Family Medicine and Director of the Program in Medical Humanities & Arts,
University of California-Irvine, School of Medicine, 101 City Dr. South, Rte 81,
Bldg 200, Ste 835, Orange, CA 92868, USA
Full list of author information is available at the end of the article
This article is a result of the Project to Rebalance and
Integrate Medical Education (PRIME), sponsored by the
Patrick and Edna Romanell Foundation. PRIME focused
on how medical ethics and humanities education are
prerequisite to professionalism formation in medical
school and residency training [3, 4]. PRIME, in turn, resulted in the creation of the Academy for Professionalism
in Health Care as an organization devoted to professionalism education [5].
The conundrum of professionalism in medical education
There are at least two significant issues to consider in
discussing medical professionalism. One has to do with
the content of professionalism itself, i.e., how it is defined. The second is essentially an implementation issue,
i.e., the methods which establish how professionalism is
achieved. These issues, and their implications for professionalism education, are discussed below.
Defining medical professionalism
The Medical Professionalism Project initiated by the
American Board of Internal Medicine Foundation, the
American College of Physicians Foundation, and the
European Federation of Internal Medicine resulted in a
professionalism charter consisting of virtue-based attributes
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Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
such as altruism, trust, honesty, patient empowerment, and
commitment to social justice [6]. Medical educatorshave
also argued for a virtue-based definition, including qualities
of compassion, integrity; truth-telling; respect for others;
self-effacement; and fidelity to patients [7–10]. Prior PRIME
publications acknowledged the importance of scientific and
clinical competence using established rigorous evidencebased medicine; while emphasizing promotion of patients’
best interests as the clinician’s primary moral consideration
(with self-interest as a subservient claim) and honoring the
exercise of the public trust, as a necessary obligation to
carry forth the fiduciary traditions of medicine (as opposed
to guild-like self-interest) [4]. Other definitions also support
the commitment to and reinforcement of moral values and
ethical principles [11, 12].
These definitions, while valuable, highlighted primarily
general, abstract virtues and attributes that have proved
difficult to translate into daily actions. Recent considerations of professionalism and professional identity formation have stressed the necessity of moving from
abstraction to practice [13, 14], highlighting what is often
referred to as phronesis or practical wisdom [15]. Medical
educators have wrestled with this challenge for the past
decade, most notably through the effort to incorporate
medical professionalism into the competency framework.
Professionalism as a competency
Indeed, it could be argued that the rise of the competency movement in medical education [16] has been an
effort to anchor generalities of training in specific, concrete, measurable behaviors. In terms of professionalism
specifically, attempting to inculcate values and virtues
often struck both learners and educators as threatening
and potentially implying character defects in students
[17]. Thus, professionalism moved from the conceptual
realm to become one of six essential medical education
competencies, sometimes viewed as a “meta”- or “ordering”
contextual competency for more technical competencies
[18, 19]. In this respect, competency-based education
appeared to offer a “solution” to the abstract nature of
earlier approaches to conceptualizing professionalism,
precisely because of its behavioral specificity. Many
medical educators found the notion of professional
competencies appealing because they seemed to offer
the promise of transforming amorphous, ill-defined,
and difficult-to-measure qualities into instrumental behaviors that were observable and assessable. Recently
more detailed “milestones” have been added to supplement and refine the six competencies, but these
remainrooted in the establishment of measurable behavior
[20]. Whether discussing milestones or competencies, the
language employed reflects a tendency in these guidelines
to prescribe, control, and shape learners in specific, reductive directions.
Page 2 of 8
Challenging a behavioral approach to medical
professionalism
Even as professionalism became identified as an area of
medical competence, some medical educators’ reflections on the topic continued to reveal a discomfort with
behavioral pedagogical approaches, instead advocating
for developing, reinforcing, and sustaining deeply held
attitudes and values [17, 21]. As Hanna and Fins write,
medical students must learn how to “be good doctors,
rather than merely to act like good doctors [18, 22, 23]”.
Others also assert that behavioral professionalism
tempts students to behave in ways that fulfill others’ expectations of professionalism without actually believing
in the virtues or principles that underpin these behaviors
[24], resulting in an emphasis on surface impression
management [25]. Others complain that in clinical settings, professionalism is simplistically and narrowly defined as a technical problem, with most solutions offered
being prescriptive, mechanical, and rule-bound [26].
Setbacks in teaching professionalism
With some notable exceptions, such as small group
reflection-based sessions [27, 28] that have shown promise most approaches to teaching professionalism, implicitly or explicitly rooted in the competency model, have
not documented significant success. An article by two
medical students claims that medical educators are more
likely to evaluate appearance, formality, and conformity
as “professional” than they are to pay attention to traits
of honor, altruism, and responsibility. This “view from
the trenches” suggests that adherence to hospital etiquette,
respecting academic hierarchy, and subservience to authority are valued more than patient-centered virtues [29].
A survey study examining student attitudes toward professionalism found that almost a third of respondents felt
professionalism education was patronizing and demeaning
[30], while a more in-depth qualitative study concluded
that medical students made a distinction between “good”
doctors and “professional” doctors, and perceived professionalism as an external and imposed construct [31].
One troubling study found that, despite required professionalism training, unprofessional behavior in students actually increased during their clinical years [32].
These and similar concerns suggest that students see
professionalism training as little more than a tool of governance [33] wielded by supervisors promoting exterior
and often trivial performance, rather than emphasizing
virtue.
The dilemma is clear. Medical educators have agreed
to define professionalism as a competency to be
achieved by measurable behaviors. They simultaneously
recognize it to be a deeper, more meaningful sense of
identity that incorporates a set of humanistic attitudes,
behaviors, and critical thinking skills. Some medical
Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
educators hope that the study of literature can help resolve this educational impasse by contributing a new
perspective to our understanding of professionalism that,
like the competency model, attempts to bridge the gap
between theory and practice, but does so in a radically
different way. Our argument is that the study of literature is where we learn, in an emotionally and critically
engaged way, to see how characters face moral dilemmas, how they resolve them, and the consequences
of those resolutions.
Implications of the Study of Literature for Medical
Professionalism
If competencies have not provided a meaningful format
for teaching medical professionalism, nevertheless it is a
fundamental contention of the PRIME scholars that professionalism must involve the application of virtues to
the practice of medicine [34]. We believe that the study
of literature, with its emphasis on the discreteness of
specific texts, has an important role to play in assisting
learners in professionalism formation. One crucial way
in which this occurs is by developing in learners the
habit of close reading, a fundamental literary skill.
How close reading relates to medical professionalism
Close reading has been defined as a disciplined reading
and rereading of complex texts to identify layers of
meaning that lead to more nuanced interpretation and
deeper, more subtle understanding [35]. It is not difficult
to imagine the translational relevance of close reading
for developing a meaningful medical professionalism tied
to the particulars of each patient’s care. Like a patient encounter, close reading first requires attentive observation –
what does the reader notice about the text? What does the
doctor notice about the patient? Interpretation follows observation – what is the meaning of the reader’s – or the
doctor’s – observations [36]? Close reading requires a wariness of superficial and facile interpretations, a clinical position that helps the clinician avoid bias, assumptions, and
judgmentalness.
A fundamental premise of close reading is the revisiting of texts to investigate alternative or complementary
meanings while recognizing that there are not necessarily any right answers. Similarly, physicians trained in
close reading may be more likely to continue to think
about their patients and to remain open to new interpretations of their actions and attitudes. In close reading,
students must not only “feel” a certain way in response
to the text, but they must know how to defend their
conclusions through reference to particular words and
passages [37]. In the clinical context, physicians must be
ready to question their initial emotional responses to patients in favor of more nuanced and complex responses
Page 3 of 8
that are based in evidence emerging from the clinical
encounter.
Close reading interrogates the structure of a particular
narrative. Why is a story told in a certain way? Who is
telling the story? Who else might tell this story? How
might different tellings change the nature of the story?
Who is the intended audience for this story? Why are
certain words selected and not others? Why are certain
metaphors employed? What seems to be important or
striking in the story? Are there contradictions or discrepancies in the story? Is the author trying to persuade
the listener of something? What has been omitted from
the story? Are there repetitions? What is the predominant tone of the story? Does it shift, and if so why? What
patterns emerge in the text [38]? Such an approach,
translated into the clinical encounter, is likely to result
in a critical professionalism through respect, engaged attention, and critical thinking within a very specific
context.
The implications of close reading for medical professionalism are far-reaching. In the remainder of this article,
we discuss how close reading leads to a different and more
critical way of understanding medical professionalism that
is grounded in the specifics of each clinical encounter as
well as the contextual specifics of race, gender, culture,
and history. It is a method that questions conventional
thinking about professionalism, complicates accepted virtues, and emphasizes individual variation.
Asking meaningful questions rather than inculcating
behavior
Although some scholars have suggested that studying literature can help medical students learn to better attend
to and understand their patients’ stories [39], cultivate
emotional resonance in patient care [40, 41], and address
burn-out through supporting more examined, fulfilled
professional lives [42], no educational process can guarantee or compel virtues, self-awareness, or wellbeing in
learners. In the real world, medical educators are not always certain how such ineffable qualities or attributes
can be meaningfully “demonstrated”. In these circumstances, what literature can do is help learners engage in
critical thinking about what the virtues and values of
medical professionalism might be; and how these actually might occur in particular situations influenced by
culture, race, disability, gender, sexual orientation, and
historical consideration.
Many professionalism issues are complicated, convoluted, and resist a simple behavioral solution (e.g., maintaining eye contact, touching a shoulder, employing rote
expressions of empathy ). Rather, questions about how
to think, feel, and behave professionally in a given circumstance are best approached as complex conundrums
in which there will likely be disagreement among those
Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
involved about the nature of the problem, the desired
resolution (if any), and the steps required to achieve it
[26]. Studying literature can help prepare learners to
grapple with these situations because stories suggest
various responses without dictating them, urge consideration of different behaviors without ordering them, and
illuminate values without oversimplifying them. Such approaches offer learners methods for exploring professionalism values that honor the distinctive, irreducible
human qualities of each patient and each circumstance
embedded in larger social and cultural contexts [43].
The countercultural perspective
Although competencies by definition require instrumental goals, literary scholars are generally more comfortable advocating non-instrumental aims for the role of
literature in medical education. One such overarching
aim is the cultivation of a critical and questioning attitude toward conventional wisdom, a so-called “countercultural” [44] perspective on medicine that implicates
both personal and professional moral development while
situating medicine within a larger sociocultural framework [45, 46]. In this view, integrating literature into the
curriculum should not blindly support the status quo in
medicine, but instead should help learners question their
own and the system’s preconceptions and prejudgments
[47] to make transparent the values, culture, and ideology of medicine [48].
Drawing on critical theory, many health humanities
scholars call for literature to open a “discursive space”
that critiques conventional assumptions about medicine
and the healthcare system [49, 50]. Dror argues that
teaching literature offers a way of rethinking medicine,
not instilling standards [48]. This approach emphasizes
“catalyz[ing] emancipatory insights” [51] and creating an
environment of “sustained critical reflection [52]”. Engaging with literature will not produce a set of measurable professionalism-specific behaviors in learners, but it
is well-suited to facilitating a critical consciousness of
self, others, and the world [53]. By stimulating critical
thinking, literature enables learners to question established
ways of understanding relationships between doctors and
patients, doctors and other healthcare professionals and
staff, and doctors and society. This standpoint asserts that,
properly executed, literature should provoke discomfort
and resistance in learners and disrupt their reflexive participation in healthcare [54, 55]. Kumagai and Wear call this
process “making strange” taken-for granted assumptions
and beliefs that may compromise humanistic care [56].
Page 4 of 8
itself. Is professionalism primarily about protecting the
“guild” of medicine? Is it about endorsing adherence to
abstract virtues? Does it have to do with translating virtuous concepts into observable and measurable behaviors?
Is it about a moral relationship between two (or more –
often many more) people under trying circumstances?
Working with a wide range of literary texts in a medical
education context can help learners discover how to frame
such questions and debate different answers.
Precisely how this happens is not fully circumscribed,
but some scholars have argued that in part students become adept at both asking questions and exploring answers through the development of moral imagination,
defined by Carson [57]as the heightened capacity to envision experience, whether one’s own or someone else’s,
from a different perspective. Importantly, examination of
literary texts reveals that in any given situation there are
multiple ways of understanding and prioritizing events,
thus making the privileging of any one perspective suspect. Charon refers to this as the capacity to visualize
others’ narrative worlds [58]. Appreciation of differing
points of view engages critical thinking through honing
learner awareness of different, often contradictory but coexisting understandings [46]. It also facilitates empathetic
orientation by encouraging emotional connection with or
recognition of characters different from oneself and
health-related roles different from one’s own [59, 60].
In discussing moral imagination, the psychiatrist
Robert Coles [61] observes that stories admonish us,
point us in new directions, and sometimes inspire us to
lead lives of greater moral integrity. We should note that
such aspirations are quite different from acquisition of
standardized behaviors to be performed regardless of the
particular situation and circumstance. Rather, selected
stories stimulate moral imagination in medical learners
by enabling them to step back from and become critically aware of their own values, beliefs, and assumptions
about professionalism and how these are influenced by
the dominant culture and other systems of influence in
which they participate. From this beginning, learners can
then imagine new possibilities for attitudes and action
based on consideration of others’ values, perspectives,
and priorities, especially those of disempowered and
marginalized individuals, as well as their own. The critical thinking that emerges from the study of literature
can help medical learners evaluate from a moral point of
view both their original assumptions and dominating
models of what professionalism is, as well as new possibilities they now envision in collaboration with their patients
from a wider social perspective [62].
Developing moral imagination
One way in which the study of literature can result in
productive discomfort for students (and teachers!) is by
critically interrogating the meaning of professionalism
The complication of professionalism values
Studying literature and reading stories reveal that even
such enshrined professionalism values as compassion do
Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
not necessarily always serve moral ends; and point out
ways in which such values need to be interrogated more
critically to understand how they might go astray. Apparently beneficial qualities such as empathy, the ability
to engender trust, and good communication skills all
can be employed to encourage docility and compliance
in less powerful individuals (i.e., patients) [2]. Some
scholars have criticized the empathic skills trained in
medical school for their potential as a tool to manipulate
care, rather than as a virtue of care [63–65]. Similarly,
compassion may devolve into a patronizing and demeaning position that approaches pity when not carefully and
respectfully placed within the context of understanding
the patient’s subjective experience of suffering within her
culture, personal history, and values. Respect can be
undermined through a mindless allegiance to autonomy
in which physicians essentially abandon patients and
families by expecting them to make medical decisions
for which they have not been sufficiently prepared. Altruism can deteriorate into rigid self-sacrifice in physicians who think patients’ wellbeing requires a persistent
neglect of personal wellbeing and life balance. By encouraging awareness of such nuances, reading literature
critically and thoughtfully has the intriguing capacity to
both challenge and deepen the virtues and attributes
that comprise medical professionalism
Standardization of professionalism?
The National Board of Medical Examiners calls for the
“standardization” of professionalism in medicine [66]. From
a literary perspective, with its emphasis on multiple, often
contradictory perspectives and the importance of acknowledging the specifics of every situation, a “standardized”
approach to professional attitudes, behaviors, and identity may not be possible. While elements of both
standardization and diversity are likely important in
formulating sufficiently complex views of professionalism [67], literature’s forte is to challenge “standardized”
views of professionalism by invoking nuance and context. The role of literature is to cultivate a thoughtful
examination of the implications and consequences of a
spectrum of different attitudes, behaviors, and identities; and to situate these within a larger socioeconomic, cultural, and political context of power and
privilege. Recalling Hanna and Fins’ concerns, we
believe that literature offers a way to help students
understand what it means to be, rather than merely act
like, a humane professional. In this way, literature urges
the opposite of “one size fits all” standardization by
emphasizing the intrinsic value of diversity in how professionalism manifests filtered through each unique
interaction of individuals (doctors, medical team, patients, and families), circumstances, and dominant
discourses.
Page 5 of 8
Widening the lens
Competency involves standardized achievement of
“correct” behaviors, a necessary narrowing to obtain reliability and consistency of assessment. Literature, on
the other hand, offers a plethora of models and possibilities for being in the world and eschews the one right
answer. Instead, the study of literature leads learners in
directions that are open-ended, unpredictable, and selfdetermining. It can both widen the lens and provide
insight into the complexities of the human condition,
suffering, personhood, and our responsibility to each
other [68]. Instead of compelling learners to narrow
their focus to concrete behaviors, literature can help
them realize that professionalism cannot be separated
from an understanding of their own humanity and that
of their patients. This is why students may learn more
about professionalism from reading War and Peace
than from an ACGME manual on professionalism
milestones.1
Assessment of professionalism
In contemplating the influence of the study of literature
on students’ understanding of medical professionalism,
how do we ascertain whether learners have actively engaged with what this concept might mean for them personally in different clinical situations? How do we
achieve insight into what capacities and habits of mind
they have developed as a result of their studies? In medicine, assessment approaches are often quantitative and
numerical. Such an approach has little to propose in determining what happens to students as a result of critically reading a story or writing a reflective essay.
Assessment of the understanding of professionalism
that students glean from literature will be better achieved
through qualitative, narrative means [69]. Longitudinal
evaluation by instructors, to allow for the maturation of
professional identity, that examines both individual and
collaborative student writing and creative projects [70]
reflecting on professional formation issues and dilemmas,
as well as narrative self-assessment of professional development might be considered according to criteria listed in
Fig. 1. In considering such student work, pedagogical theory in the humanities suggests that what is important is
transparency in how the student thinks, rather than the
specific nature of the conclusions they reach [71, 72].
Following this line of reasoning, we suggest that projects, essays, and other relevant products should be examined for their ability to make students’ thinking about
professionalism formation and dilemmas visible and
plain. This might mean, for example, attending to how a
student both develops and questions an argument, considers multiple perspectives, understands emotional sequelae for both self and others, and has some sense of
the relevant cultural, historical, familial, and personal
Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
Page 6 of 8
Fig. 1 How we know students have engaged with professional formation through the study of literature
factors implicated. Further, research suggests that professionalism decisions in medicine are highly context
dependent [73], are influenced by a wide range of considerations, and are surprisingly shifting and malleable
depending on the input of peers [74]. These findings
suggest that assessment of professionalism cannot be
global and general, but must be situation specific.
Since it is impossible to anticipate all professionalism dilemmas, it is particularly important to nurture habits of
mind such as are outlined above that can be brought to
bear on unique clinical encounters. For example, Kuper
suggests that students’ increasing emotional awareness,
self-reflection, and capacity to grasp ambiguity might be
considered as proxy outcomes for actual patient interaction skills [75]. Here again, such qualities cannot be
measured through a Likert scale, but might be explored
through an evaluative process that explores students’
growth on these dimensions, and explores how these qualities can be translated into real-world situations. Charon
talks about “narrative evidence”, or the insights and sensibility offered through careful attentiveness to the patient’s
story [76]. We might do well to refer to this concept in
assessing what medical students learn from exposure to
literature – i.e., what have they discovered about how to
access the person of the patient in a medical interview?
How has their understanding evolved regarding the ways
in which a patient’s cultural background, class, family and
community affect her response to illness? Within this
framework, evaluation of learners might best be understood as a kind of conversation between faculty and student rather than a definitive, top-down assessment.
Charon also points out that the true metrics of success
have to do with clinicians’ attitudes, behavior and interactions in the clinical arena, and the effects these have
on their patients [77]. Following Charon’s lead, we suggest that the gold standard of professionalism is patient
and family assessment of these dimensions of care in
their student doctors. By this we do not mean yet more
patient satisfaction measures of learners. Rather, timeconsuming as it would be, obtaining narrative responses
from patients and families about how they experience
the trustworthiness, respectfulness, non-judgmentalism
of learners, their capacity to listen and care and to demonstrate compassion in action by thinking outside the
box, would be a truly meaningful form of assessment.
Such an approach is an essential way to reveal to what
extent nuanced scrutiny of stories, poetry, and essays by
patients and physicians affects the way learners interact
with and behave toward actual patients and families. By
making such inquiries of patients and their family members, we would learn how students translate the professionalism values, attitudes, and interactive skills they
have discovered in literature into each unique of clinical
encounters.
Conclusion
In summary, we suggest that literature is an essential
element of medical education that, through the method
of close reading, contributes intellectual inquiry, emotional
awareness, sociocultural context, and a countercultural perspective to questions regarding medical professionalism.
Narrative and storytelling broaden and make more complex
the ethical context of care provided by students and faculty.
They assist learners in rigorously and feelingly examining,
in specific evocative contexts, what it means to be a doctor
in relationship with patients and families within a framework of larger social dynamics and discourses. Literature
can deepen the understanding of medical professionalism,
Shapiro et al. Philosophy, Ethics, and Humanities in Medicine (2015) 10:10
as many medical educators desire; but it cannot simultaneously promote assessment practices that rely on facile
quantitative behavioral responses. If medical education
can not only tolerate but embrace the opportunity to challenge the assumptions and beliefs its learners hold about
the profession, literature has much to offer professionalism formation.
Endnote
1
Some examples of short stories and poems that encourage self-examination and broader thinking include: “Laundry” by Susan Mates, “Touching” by David Hellerstein,
“Carnal Knowledge” by Danny Abse, “Skin for Ricky” by DL
Scheidermayer, “Baptism by Rotation” by Mikhail Bulgakov,
“Imelda” by Richard Selzer, and “Talking to the Family” by
John Stone. While doctors are not the only or the most important storytellers, such texts are especially useful entry
points for medical learners uncertain as to the value of
studying narratives as part of their medical education.
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Competing interests
All authors declare that they have no competing interests.
14.
Authors’ contributions
JS was primarily responsible for the review of the literature and the
conceptualizat
