Jack Coulehan

Viewpoint: today's professionalism: engaging the mind but not the heart.

Professionalism is au courant in medicine today, but the movement to teach and evaluate professionalism presents a conundrum to medical educators. Its intent is laudable: to produce humanistic and virtuous physicians who will be better able to cope with and overcome the dehumanizing features of the health care system in the United States. However, its impact on medical education is likely to be small and misleading because current professionalism curricula focus on lists of rules and behaviors. While such curricula usually refer to virtues and personal qualities, these are peripheral because their impacts cannot be specifically assessed. The author argues that today’s culture of medicine is hostile to altruism, compassion, integrity, fidelity, self-effacement, and other traditional qualities. Hospital culture and the narratives that support it often embody a set of professional qualities that are diametrically opposed to virtues that are explicitly taught as constituting the “good” doctor. Young physicians experience internal conflict as they try to reconcile the explicit and covert curricula, and they often develop nonreflective professionalism. Additional courses on professionalism are unlikely to alter this process. Instead, the author proposes a more comprehensive approach to changing the culture of medical education to favor an approach he calls narrative-based professionalism and to address the tension between self-interest and altruism. This approach involves four specific catalysts: professionalism role-modeling, self-awareness, narrative competence, and community service.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Conflicting Professional Values in Medical Education

Ten years ago there was little talk about adding “professionalism” to the medical curriculum. Educators seemed to believe that professionalism was like the studs of a building—the occupants assume them to be present, supporting and defining the space in which they live or work, but no one talks much about them. Similarly, educators assumed that professional values would just “happen,” as trainees spent years working with mentors and role models, as had presumably been the case in the past. To continue the metaphor, when educators did discuss ethics and values, they tended to focus more on external building codes than on the nature of construction materials. Building codes are designed to ensure the publics safety by establishing procedures and standards. Likewise, the “new” bioethics of autonomy and informed consent that entered the medical curriculum in the 1970s and 1980s was oriented primarily toward protecting human rights (e.g., protecting patients from clinicians and clinicians from patients) by codification (e.g., who should decide and under what circumstances). In fact, educators explicitly warned students against acting on their personal or professional values in a misguided way—that is, in the absence of adequate ethical constraints, a type of behavior that came to be labeled, pejoratively, as paternalism.

A Gentle and Humane Temper: Humility in Medicine

Humility is the medical virtue most difficult to understand and practice. This is especially true in contemporary medicine, which has developed a culture more characterized by arrogance and entitlement than by self-effacement and moderation. In such a culture, humility suggests weakness, indecisiveness, or even deception, as in false modesty. Nonetheless, an operational definition of medical humility includes four distinct but closely related personal characteristics that are central to good doctoring: unpretentious openness, honest self-disclosure, avoidance of arrogance, and modulation of self-interest. Humility, like other virtues, is best taught by means of narrative and role modeling. We may rightly be proud of contemporary medical advances, while at the same time experiencing gratitude and humility as healers.

Two of Them

The old Russian couple in adjoining chairs teeter toward each other and tell me everything. She demonstrates the jolt at the edge of sleep by jabbing a finger at me, vindicatively. He shows his scalp-it crawls with emptiness at night and keeps him up. There, he bats it behind his ear. I think he sold diamonds for a living, enough to convince himself, he said once, its not much of a life. At the end of her list is Need sleep underlined twice, and What happened to my eyes?

Maintaining Confidentiality in Qualitative Publications

Protecting the privacy of study participants is a core tenet of research ethics. It is usual practice to change the names of study participants when publishing qualitative research, but for a number of years, Qualitative Health Research (QHR) has maintained that this procedure in itself is inadequate to disguise a participant’s identity. The number of demographic tags, or identifiers, linked to the person in the article may compromise confidentiality—the greater the number of tags that are included, the easier it is to identify the person. To minimize the risk of violating confidentiality, QHR will not publish a table that lists participants’ demographic information—age, gender, occupation, employment, disease, and so forth— line by line. Such information, especially because of the small samples we use in qualitative research, might enable an interested party to identify a specific person, and to scan the article for what was reported about that individual, tracing what that person said throughout the article.

What the world needs now.

‘‘What the world needs now is now is love, sweet love. . .’’ Two ragged rows of enthusiastic faces on the stage in the church basement belt out the old Burt Bacharach song. It’s graduation day for my grandson’s preschool class. The children hold hands, as they sing off-key as loud as they can, ‘‘Love’s the only thing there’s just too little of.’’ Afterward, at the reception, the tune remains with me. And the words carry me back in a kind of sweet melancholy to my office in Pittsburgh thirty years ago, where Catherine Blakemore sits beside my desk explaining to me for the umpteenth time that love is what the world needs, what she needs. . . and what the demons have deprived her of. Ms. Blakemore was in her 50s when I first met her, but the waxlike smoothness of her face made her seem much younger. She wore stylish clothes, with a silk babushka over her frizzled hair. Despite seeming at first glance impeccably dressed, Ms. Blakemore usually arrived with at least one sartorial glitch – a quarter-inch strip of petticoat below her dress, or a button unbuttoned on her blouse. She was intelligent and charming, even coquettish at times. Her medical problems included hypertension, osteoporosis, and lumbago. However, Ms. Blakemore’s other, unspoken, diagnosis was paranoid schizophrenia, a condition that first appeared when she suffered a ‘‘nervous breakdown’’ as a college student in New England. She recovered well enough to graduate, but a year or so later, shortly before her scheduled wedding, she had a second breakdown. The marriage fell through, and she resided for several months in a private hospital. By the time I knew her, Ms. Blakemore

Deep hope: A song without words

Hope helps alleviate suffering. In the case of terminal illness, recent experience in palliative medicine has taught physicians that hope is durable and often thrives even in the face of imminent death. In this article, I examine the perspectives of philosophers, theologians, psychologists, clinicians, neuroscientists, and poets, and provide a series of observations, connections, and gestures about hope, particularly about what I call “deep hope.” I end with some proposals about how such hope can be sustained and enhanced at the end of life. Studies of terminally ill patients have revealed clusters of personal and situational factors associated with enhancement or suppression of hope at the end of life. Interpersonal connectedness, attainable goals, spiritual beliefs and practices, personal attributes of determination, courage, and serenity, lightheartedness, uplifting memories, and affirmation of personal worth enhance hope, while uncontrollable pain and discomfort, abandonment and isolation, and devaluation of personhood suppress hope. I suggest that most of these factors can be modulated by good medical care, utilizing basic interpersonal techniques that demonstrate kindness, humanity, and respect.

Human contexts: Medicine in Society at Stony Brook University School of Medicine.

Humanities teaching was introduced at Stony Brook University School of Medicine by Edmund Pellegrino, the first dean of the Medical School and founder of the Health Sciences Center. Since 1990, “Medicine in Society” has been a substantial presence throughout the curriculum, introducing students to the perspectives of a wide range of humanities disciplines as they apply to health care, and continuing as a sustained presence throughout the four years of training. Medicine in Society serves as a reminder that medicine is a human and communal endeavor, situated in sociocultural contexts, reliant on human values, and articulated most often through narratives. The authors describe the structure and function of the Medicine in Society curriculum and the Institute for Medicine in Contemporary Society, summarize their evaluation of the program, and outline their plans for meeting current and future challenges.

Suffering, Hope, and Healing

Suffering is the experience of distress or disharmony caused by the loss, or threatened loss, of what we most cherish. Suffering involves dissolution, alienation, loss of dignity, and/or a sense of meaninglessness. Hopelessness is an extreme manifestation of suffering. However, hope is a natural human resource that can relieve suffering and contribute to healing. Hope is also more flexible and resilient that physicians, who traditionally withheld or manipulated the truth about dire prognoses, believed it to be. Maintaining hope, especially deep hope, is an antidote to suffering.