Professionalism Viewpoint: Learning Professionalism: A View from the Trenches Andrew H. Brainard, MD, MPH, and Heather C. Brislen, MD Abstract The authors, medical students immersed in learning professionalism, observe that most of the professionalism literature misses the mark. Their views on professionalism education, although not the result of qualitative research, were gained from four years of conversations with students from a dozen medical schools, plus online student discussions, focus groups, and meetings with supervisors from five schools. The authors propose that the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students’ virtue, confidence, and ethics than is generally acknowledged. The authors maintain that deficiencies in the learning environment, combined with the subjective nature of professionalism evaluation, can leave students feeling persecuted, unfairly judged, and genuinely and tragically confused. They recommend that administrators, medical educators, residents, and students alike must show a personal commitment to the explicit professionalism curriculum and address the hidden curriculum openly and proactively. Educators must assure transparency in the academic process, treat students respectfully, and demonstrate their own professional and ethical behavior. Students overwhelmingly desire to become professional, proficient, and caring physicians. They seek professional instruction, good role models, and fair evaluation. Students struggle profoundly to understand the disconnect between the explicit professional values they are taught and the implicit values of the hidden curriculum. Evaluation of professionalism, when practiced in an often unprofessional learning environment, invites conflict and compromise by students that would otherwise tend naturally toward avowed professional virtues. Acad Med. 2007; 82:1010–1014. We wrote this essay to describe how we are learning medical professionalism as medical students, especially in the hospital environment in our clinical years. It is not a research report or a scientific article on medical students’ experiences of professionalism education. Rather, it is our view from the trenches. We will describe observations and experiences, and relate a few of the many stories collected from students attending a dozen medical schools across the country. We have assembled specific narrative anecdotes over the last four years from five medical schools, using formal and informal focus groups, online medical student discussion groups, conversations with our peers, and meetings with our supervisors. The anecdotes that we have included here are only a small fraction of those that we could have shared, but they are representative. In our experience, they are the sort of stories shared by medical students at every social engagement and get-together. Although we collected these anecdotes unofficially and without using modern qualitative techniques, we feel that they are a sufficiently accurate snapshot of the medical student experience at a variety of institutions and for a variety of specialties, academic performance levels, and degrees of experience. We hope that future research will prove that our snapshot is less representative than we fear it is, and will also uncover solutions that we have missed to the problems presented below. Background The academic study of medical professionalism is becoming very common, and there are several reviews, articles, and books on teaching professionalism. 1–4 However, as current medical students immersed in learning professionalism, it is our observation that most of the current literature on this topic misses the mark. We propose that the chief barrier to medical professionalism education is unprofessional conduct by medical educators. In practice, unprofessional conduct by faculty and residents is protected by an established hierarchy of authority. 5–7 We students feel no such protection, and maintain that the current structure of professionalism education does more to harm students’ virtue, confidence, and ethics than is generally acknowledged. Medical educators, like the students they teach, are forced to operate within the larger medical culture. 8 Rather than the consistent teaching or expert caregiving that we would wish for as the standard, providers in academic hospitals seem to operate on an ethic of crisis control. 9,10 As in any crisis, the environment has evolved to accept substandard professional behavior in exchange for efficiency or productivity. 11,12 Established At the time this article was written, Dr. Brainard was a medical student at the University of New Mexico School of Medicine, Albuquerque, New Mexico. He is now a resident in emergency medicine at St. Luke’s Bethlehem Hospital Networks in Bethlehem, Pennsylvania. At the time this article was written, Dr. Brislen was a medical student at the University of New Mexico School of Medicine, Albuquerque, New Mexico. She is now an internal medicine resident at the University of New Mexico, Albuquerque, New Mexico. Correspondence should be addressed to Dr. Brainard, 801 Ostrum St, Bethlehem, PA 18015; telephone: (610) 954-4903; e-mail: (brainaa@slhn.org). Academic Medicine, Vol. 82, No. 11 / November 2007 1010