Cover Story
The Mentor's Image
By Howard Bell
Observing others is the best way for students to learn professionalism.
True story: A prominent Minneapolis specialist marched into the oncology ward on rounds. The usual gaggle of fellows, residents, and students followed like ducklings. The specialist grabbed a patient’s chart, mumbled under his breath, scribbled some notes, thrust the chart at the nurse, then marched out of the room. The patient, who was alert and sitting up against plumped pillows, turned to the nurse and said, “Who was that? The doctor or the janitor?”
The exchange was witnessed by a University of Minnesota medical student doing rounds. And it made such a lasting impression that 25 years later, she still remembers it clearly.
The incident illustrates the fact that technical know-how isn’t all that makes a physician good. Patients want doctors who connect with them as human beings, who will call them by their names, look them in the eye, and treat them like a person—not a diagnosis. They want to be asked what they think, told what the doctor thinks, and briefed about what’s going to happen before it happens. They want a doctor who is compassionate, empathetic, altruistic, and honest. In short, they want their doctor to be professional. More specifically, they want what academics who study the matter call “humanistic professionalism”—that is, medical care that combines the appropriate application of scientific knowledge and technical skills with acknowledgement of and respect for the emotional, social, and cultural needs and preferences of individual patients and their families.
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Six physicians share stories about doctors who inspired them. |
It’s not fluff. Peer-reviewed studies show patients treated this way are more satisfied with the care they receive and have better outcomes. Professionalism may be just one thread in medicine’s fabric. But it’s an important thread that holds together the rest—patient confidentiality, quality of care, evidence-based practices, informed consent, and avoiding conflicts of interest, to name a few. Pull it and medicine as a profession unravels like a cheap lab coat.
The Accreditation Council for Graduate Medical Education (ACGME), which evaluates and accredits medical residency programs, requires that residents demonstrate six competencies, professionalism being one of them. To be professional, the ACGME says residents must demonstrate (not just be taught) respect, compassion, and integrity. They must be responsive to the needs of patients and society in a way that supercedes self-interest. They must be accountable. They must be ethical in providing and withholding care, ensuring patient confidentiality, receiving informed consent, and practicing the business of medicine. They must be sensitive to patients’ culture, age, gender, and disabilities.
Sounds good, but how do you teach someone these behaviors and attitudes, then evaluate how well they’ve learned them? “The devil is in the details,” says Frederic Hafferty, Ph.D., who teaches on professionalism at the University of Minnesota Medical School, Duluth campus. “Medicine has done a good job of defining what professionalism is,” he says. “Now we need to come up with effective ways to teach it.”
The medical schools at Mayo and the University of Minnesota are attempting to do just that. Courses such as the university’s Physician and Society and Mayo’s The Art of Medicine are the introductory primers on professionalism. And simulated doctor-patient interactions boost student confidence and prepare them for the real game. But the best way to teach professionalism is to model it, according to Peter Weissmann, M.D., an associate professor of medicine at the University of Minnesota Medical School and associate program director of medical education at Hennepin County Medical Center in Minneapolis. Weissmann has studied how the good role models do it on inpatient units at four U.S. medical schools.
To mentor professionalism well requires three things, according to Weissmann. First, start with good role models. Second, give students and residents time to reflect on their experiences—alone and in groups. “A good mentor,” says Weissmann, “guides students in the process of self-
reflection by asking the right questions.” What happened during this particular patient encounter? How did you react? How did the patient react? What would you do differently next time? Third, mentor professionalism in an environment that practices what it preaches—in schools and medical centers that have what academics call a “positive hidden curriculum.” The term “hidden curriculum” refers to the messages students get from observing the signage, informal conversations, and behaviors of others.
A Mentor for Mentorship Programs
The University of Minnesota Medical School has been mentoring professionalism through the Rural Physician Associate Program (RPAP) for 36 years. The program is arguably closer than anything else at the university to an apprenticeship. “It’s very impressive how they go in as medical students and come out as physicians,” Gwen Halaas, M.D., RPAP director, says of participants. “And that has everything to do with professionalism.”
Long-term immersion mentoring with one doctor is the key. Third-year students work and spend free time with one physician in a rural community for nine months. Mentors are largely self-selected. More than half are RPAP graduates themselves who are passionate about the experience. Students participate in all aspects of examining, diagnosing, and treating patients. They deliver bad news. They make difficult decisions. They experience the clinic slice and the hospital slice of the system at once. In the process, they adopt their mentor’s professional values and practices.
After a few months, students become trusted, valued members of their clinic and of the community. “It’s active learning in the real world,” Halaas says. Because they spend so much time with their mentor, there’s plenty of opportunity for informal discussion and self-reflection and time to watch unfold the ongoing story of a particular patient, which is rarely possible during a standard six-week rotation. And there’s plenty of time for conversations in the hallway, jokes told in the cafeteria, and stories told about “that great case.”
“Mentors and students become life-long friends,” Halaas says. “We’re setting the stage for their career. It’s a formative immersion into their future. Finding their calling is part of the immersion. They find their vocation and their practice style. Developing a professional persona is part of it all.”
Measuring just how professional an RPAP student has become is “a very challenging task,” Halaas admits. Personal essays reflecting on their experiences are one way RPAP measures maturity, morality, virtue, and ability to respect and develop trusting relationships with patients. The RPAP formula seems to work: 30 percent of University of Minnesota medical students who receive the Gold Foundation Humanism Award are RPAP grads.—H.B. |
Mayo and the university are taking different approaches to restructuring how they mentor professionalism. But their approaches have some things in common. They include Weissmann’s three essential ingredients, which are now widely accepted as necessary for effective mentoring. And they formalize what traditionally was fairly informal—the selection of mentors and how they go about mentoring. They’re extending the length of time students spend with their mentors—in the U’s case from one year to four. They’re coming up with specific learning goals and structuring formal arrangements in which students meet with mentors one on one and in groups.
These new approaches differ from traditional mentoring, according to Hafferty, who says mentor-student relationships have usually been short-term—often just a few weeks and largely unstructured—and with physicians in the community who agree to let students shadow them. Says Hafferty: “The mentor may be a good role model for professionalism or not so good. The student gets what they get.”
Big Changes at the U
The university is placing “a huge emphasis on improving the quality and quantity of mentoring medical students get,” says Jim Pacala, M.D., M.S., a geriatrician and distinguished university teaching professor in the family medicine and community health department, who with Kathleen Watson, M.D., associate dean for students and student learning, has co-chaired a work group focused on improving the way the medical school fosters professionalism. The plan at this point is to place students in “learning communities,” groups of roughly 10 students from each of the class years. Currently being designed and piloted under Watson’s leadership, each learning community will have the same mentor for the entire four years. They’ll also be assigned a group of other faculty mentors and peers who will offer guidance, the opportunity for reflection, and advice. Right now, students are assigned a mentor or a “master tutor” for only the first year.
Learning communities have been likened to the Hogwarts houses in Harry Potter—Hufflepuff, Gryffindor, Ravenclaw (but hopefully not Slytherin). The mentors who lead them will be handpicked members of the faculty. They must be excellent at small-group facilitation. They must be able to initiate and moderate high-quality discussions about meaty topics. They must be good at evaluating the accuracy of student self-perceptions. They must also work well with other mentors who are guiding students in other aspects of their training. And, of course, they must practice the professional behaviors and attitudes they’re trying to instill in students.
Each learning community will meet regularly. Beginning in the fall of 2007, one of the mentor’s jobs will be to cultivate a professional identity in first-year students, according to Pacala. In the groups, students will learn that professionalism has two levels. Level one is the rules and standards found in codes of conduct: Tell the truth. Fulfill your responsibilities. Don’t break the law or abandon patients. “These are the easiest to teach, evaluate, and enforce,” Pacala says.
Level two is the meatier issues of ethics and judgment. How do you feel about health access disparities by socioeconomic class? What are your responsibilities at home versus at school? How do you preserve objectivity when your research is funded by a special interest? What exactly does it mean to be altruistic, and when do you draw the line and put yourself and your family first? How do you deal with an impaired colleague? How do you think about your own strengths and weaknesses? How do you incorporate spirituality into your practice? How do you feel about working with someone of the opposite gender who is your peer—or supervisor? How do you feel about old people, obese people, poor people, and non-Caucasians? “You can’t switch this stuff off when you’re seeing patients,” Pacala says.
The best way a mentor can help students become aware of these issues, according to Pacala, is to overtly raise a topic, provide them with factual material and opinion, and then let them discuss it in a respectful manner. “They have to be able to kick these issues around in a protected environment free from repercussions for what they say,” Pacala says.
Students will meet one on one with their mentor each quarter. “We’ll do the usual advice and counseling,” Pacala says. “We’ll also do plenty of healthy self-reflection, where students discuss their mistakes and successes, their strengths and weaknesses. We’ll talk about patient encounters, experiences they’ve had, and challenges they face at school and at home.” The worst way to teach these deeper aspects of professionalism, Pacala adds, is to teach them as if there’s a black-and-white, right-or-wrong answer.
Mayo’s Five Steps
Mayo Clinic does not have a formal institutionwide approach to mentoring at this time, but the medical school is developing one in which mentors will be carefully selected for their ability to model professionalism. Mayo has identified five steps to guide the process of selecting mentors and is revamping how they go about mentoring, according to Colin West, M.D., Ph.D., an assistant professor of internal medicine.
“First,” West says, “identify those physicians who are excellent role models for professionalism and watch how they do it.” Second, give mentors the time to mentor, and reward them for it. “Rewarding physicians who are good at getting NIH funding is fine,” he says, “but not to the exclusion of the compassionate doctor who’s good at teaching professionalism. That’s an ability that needs to be rewarded, too.” Third, give students hands-on experience—the more the better, the earlier the better. Being told how to break bad news is good. Better is showing them how to do it. Better yet is a mentor who, when the time is right, says Do it yourself. I will observe you and bail you out if you need me. “Mayo is doing much more of this active learning than we used to,” West says. Fourth, offer the opportunity for group discussion among students and faculty about specific patients. What’s happening? What are we going to do now? How and why? “We’re doing more of this at the bedside with the patient participating,” West says. Finally, give students time to reflect on what they’ve seen and done.
Collegiality is also part of teaching professionalism, according to Steven Rose, M.D., vice dean of Mayo’s School of Graduate Medical Education. “The hierarchical structure of old is gone,” he says. “No more white coats of different lengths. Doctors learn from nurses. We’re all colleagues regardless of out jobs.”
Rose says it used to be that the ACGME wanted to see what students were taught. Now it wants to see what students have learned. One way Mayo measures that is with 360-degree evaluations. “Everyone who participates in an episode of care evaluates that resident,” Rose says. “It’s a useful tool because some residents don’t realize they’re being impolite to patients or disagreeable with allied staff.” Mayo also uses written self-assessments and peer assessments. “If someone’s taking advantage of his peers or not pulling their weight,” Rose says, “this really comes out.”
Walk the Walk
Even the best mentors won’t get the message of professionalism to sink in if the medical center where they teach is pervaded by behaviors and attitudes that contradict the qualities they’re trying to teach. “All facilities have a statement on professionalism that talks about respect and dignity,” West says. “But the question is: Does the leadership at that institution truly practice and support what they say? You’ve got to walk the walk and talk the talk, but too often what students get is ‘do as we say, not as we do.’ The challenge is to get an entire institution walking the walk. We’re trying to figure out how to do that better.”
So is everyone else. Formalizing how they select and evaluate mentors is a good start to combating negative attitudes and behaviors. “It’s crucial that mentors practice what they preach,” West says. “If mentors spend time complaining about reimbursement and productivity, students pick up on that.” Weissmann explains.
When medical center policies encourage doctors in the trenches to obsess over relative value units and productivity quotas, it sends the message that this is what it means to be a doctor. It sends the message that professionalism is not about quality of care. It’s about seeing as many patients as you can and getting on drug company speakers bureaus to supplement your income. “Students pick up on the organizational values prevalent in whatever setting they find themselves,” Weissmann says. “You’ve got to do unto others as you would have them do unto others.”
Students themselves can be an obstacle to the success of mentoring, according to Hafferty, because some are suspicious of the very notion. “They think it’s old school and nostalgic,” he says.
Others simplistically think professionalism means nothing more than etiquette. Start with a good haircut, add a nice suit, and garnish with please and thank you and you have instant professionalism. Some students, according to Hafferty, think altruism is an Orwellian euphemism for “Work harder and longer for less money at the expense of your personal life.”
Or they confuse professionalism with understanding the business of medicine and try to work the system to their advantage. “The student who believes professionalism means learning the business of medicine so they can be a financial success and maximize their return on investment has come to a professional fork in the road,” says Hafferty. Down one path is the desire to prevent and relieve suffering by providing the highest quality of care. Down the other is commercialism. “The two paths merge,” he says, “only if the student wants to learn the business of medicine so they can take better care of patients.”
Dissatisfaction about the current state of the U.S. health care system is a big contributor to complaints and negative attitudes. Rather than wallow in discontent, Pacala says clinics and hospitals as a whole need to get over it and get on with it—strive for humanistic professionalism at all levels in all departments. “Twenty years ago when I was a student,” says Pacala, “I used to get so #$!@&! tired of hearing doctors gripe and bemoan the end of medicine—how corporations were taking over, physician autonomy is gone, and the golden age of medicine is over. That’s ridiculous. Medicine today can do more than ever for patients—and patients are what it’s all about. We need to keep that in mind.”
Maybe so, but Hafferty wonders how well doctors can mentor professionalism (and students can learn it) when there is increased convergence of medicine and commercialism. “Unfortunately for students,” says Hafferty, “medicine has evolved from a cottage industry to a business where corporate values have shifted priorities to those dictated by shareholders, boards of directors, and bottom lines. Commercialism and professionalism in medicine are like oil and water, and there’s a long history of troubled relationships between industry and medicine and between industry and medical education.”
Rescuing medicine from this priority shift to commercialism by re-instilling old-school professionalism is, according to Hafferty, one of the big three movements in medicine—along with the emphasis on evidence-based medicine and patient safety. The common denominator underlying these movements is quality of care. Unless you preserve professionalism, quality takes a hit.
Minnesota’s medical schools and residency programs are engaged in the rescue. If they succeed, perhaps tomorrow’s doctors won’t be mistaken for the janitor. MM
Howard Bell is a medical writer in Onalaska, Wisconsin.