When we speak of good medicine, we typically mean the science of medicine and its clinical quality: Is the doctor providing the most appropriate diagnosis and treatment for my illness? Over the past quarter century, advances in the medical sciences and subsequent improvements in the technical ability of physicians have resulted in our increasing ability to deliver good, science-based medicine. Undoubtedly, the day will come when the details of the Krebs cycle, baptismal information that almost all first-year medical students commit to memory, will prove to be relevant to providing good medicine at the bedside.
Despite continuing scientific advances, the practice of good medicine requires more than applying the right science at the right time for a specific ailment. Good medicine demands that we practice medicine also as an art because there will always be the point at which science cannot stop the inevitable, the point at which compassion and comfort are all a physician can give to patients in need. Today, the challenge confronting the medical profession is how to educate physicians not only in the scientific but also in the artful practice of medicine.
In medical school, a burgeoning number of courses that cover topics ranging from the doctor-patient relationship to the medical humanities have been developed to educate for professionalism. But while there are more ethics courses available today than when I was a medical student, the time and effort dedicated within the formal curriculum to the artful practice of medicine remain limited and, some say, ineffectual. Factors in medical school that contribute to the challenges of teaching ethics and professionalism range from competing curriculum demands, inadequate support and training for role models and mentors, student resistance to such courses, and the belief that no one can be trained to be compassionate by taking a course1-4.
Following medical school, the barriers to educating for professionalism are even more daunting. Stress related to long work hours, lack of formal social support, and the burden of caring and treating many and diverse patient populations create a learning environment that works against the preservation and cultivation of professionalism. These cumulative experiences in the undergraduate and graduate medical settings lead to a "hardwiring" that makes professional attitudes and behavior among practicing physicians that much less modifiable. Nevertheless, I have always found the logic behind the notion that individuals cannot learn to be more compassionate or empathic somewhat flawed, when there is ample evidence that medical students and residents learn and habituate to conduct that is the antithesis of professionalism5-9.
Given these educational challenges, there is a growing realization and urgency among leaders in medicine that a more systematic approach must be developed for imparting ethics competencies and then assessing whether those competencies have been attained10-12. In short, it seems, paradoxically, that the art of medicine must have a more scientific basis if it is to promote the practice of good medicine. Medical school faculty are increasingly more innovative as they refine ethics curricula, both formal and informal, to address the educational needs of students. The Accreditation Council for Graduate Medical Education has adopted core competencies that doctors in accredited residency training programs must demonstrate. Among these core competencies is the ability to provide ethical care, an accreditation requirement that should lead to structural reforms of the residency workplace that will foster the practice of compassionate care. Lastly, there appears to be a growing demand for ethics CME courses, and this trend will likely accelerate further as more states require these types of lifelong learning requirements for licensure.
A not-so-famous man once said, "If you can't measure it, it's less likely to be important." In the case of good medicine, it is widely accepted that we need to measure how well physicians are providing clinical care so that we can continue to make improvements. I would argue that this logic applies not only to the science of medicine, but also in many important respects to the art of medicine—otherwise it simply becomes idealistic rhetoric. Leaders in medicine must work together to develop effective ways of imparting and evaluating the ethical skills and competencies of physicians.
- Wilkes MS, Usatine R, Slavin S, Hoffman JR. Doctoring: University of California, Los Angeles. Acad Med. 1998;73(1):32-40.
- Makoul G, Curry RH, Novack DH. The future of medical school courses in professional skills and perspectives. Acad Med. 1998;73(1):48-51.
- Maheux B, Beaudoin C, Berkson L, et al. Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools. Med Educ. 2000;34(8):630-634.
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- Knight JA. Moral growth in medical students. Theor Med. 1995;16(3):265-280.
Rosner F. Graduating medical residents: Will they be ethical, wise, strong, and honorable? Isr J Med Sci. 1994;30(11):846-849.
- Elnicki DM, Linger B, Asch E, et al. Patterns of medical student abuse during the internal medicine clerkship: perspectives of students at 11 medical schools. Acad Med. 1999;74(10 Suppl):S99-S101.
- Kassebaum DG, Cutler ER. On the culture of student abuse in medical schooL. Acad Med. 1998;73(11):1149-1158.
- Halpern R, Lee MY, Boulter PR, Phillips RR. A synthesis of nine major reports on physicians' competencies for the emerging practice environment. Acad Med. 2001;76(6):606-615.
- Rabinowitz HK, Babbott D, Bastacky S, et al. Innovative approaches to educating medical students for practice in a changing health care environment: the national UME-21 project. Acad Med. 2001;76(6):587-597.
- Finnochio LJ, Bailiff PJ, Grant RW, O'Neil EH. Professional competencies in the changing health care system: physicians' views on the importance and adequacy of formal training in medical school. Acad Med. 1996;70(11):1023-1028.