Hidden Curriculum untuk Memahami Profesionalisme Pendidik
2007; 29: 54–57
Addressing the hidden curriculum:
Understanding educator professionalism
ANITA DUHL GLICKEN & GERALD B. MERENSTEIN
University of Colorado at Denver and Health Sciences Center, Aurora, USA
Med Teach Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/23/14
For personal use only.
Abstract
Several authors agree that student observations of behaviors are a far greater influence than prescriptions for behavior offered in
the classroom. While these authors stress the importance of modeling of professional relationships with patients and colleagues, at
times they have fallen short of acknowledging the importance of the values inherent in the role of the professional educator. This
includes relationships and concomitant behaviors that stem from the responsibilities of being an educator based on expectations of
institutional and societal culture. While medical professionals share standards of medical practice in exercising medical knowledge,
few have obtained formal training in the knowledge, skills and attitudes requisite for teaching excellence. Attention needs to be
paid to the professionalization of medical educators as teachers, a professionalization process that parallels and often intersects the
values and behaviors of medical practice but remains a distinct and important body of knowledge and skills unto itself. Enhancing
educator professionalism is a critical issue in educational reform, increasing accountability for meeting student needs. Assumptions
regarding educator professionalism are subject to personal and cultural interpretation, warranting additional dialogue and research
as we work to expand definitions and guidelines that assess and reward educator performance.
Over the past five years, several articles and reports have
attempted to identify attributes and themes of medical
professionalism (National Board of Medical Examiners 2003;
Lynch et al. 2004; Surdyk et al. 2004). These papers document
historical attempts to identify strategies to teach and assess
these characteristics in medical professionals and students.
Many of the commonly accepted attributes of professionalism
remain consistent with those identified by Abraham Flexner
(1915) in the early twentieth century in his descriptions of
characteristics of the medical professional. In a recent special
report from the Association of American Medical Colleges, Inui
(2003) cites several taxonomies of domains summarizing
common characteristics associated with professionalism. Lists
include characteristics of altruism, honor and integrity; caring
and compassion; respect; responsibility; accountability; excellence and scholarship; and leadership. Inui notes that these
attributes are jointly endorsed by the American Board of
Internal Medicine (ABIM), the American College of Physicians
and the European Federation of Internal Medicine.
Accreditation bodies also incorporate these characteristics
into their expectations for program curricula. The
Accreditation Council for Graduate Medical Education (1999)
includes professionalism as one of six general competences
required to be taught and assessed in all residence programs
and the Association of American Medical Colleges’ Medical
School Objectives Project (1998) highlights altruism and
dutifulness as associated areas that should be taught in all
medical schools. Similarly, the General Medical Council of the
UK (2006), the Canadian Medical Association (Kondro 2002)
and the CanMeds 2000 Project of the Royal College of
Physicians and Surgeons of Canada (2005) all mandate
professionalism as a priority in medical education and
professional practice.
Many of these endorsements are based on the notion that
physicians ‘develop’ or reform their concept of professionalism
over the course of their education and that various attributes
can be taught, modeled and institutionalized. In a recent
publication Charlotte Rees (2005) describes a model of protoprofessionalism, which assumes that professional development is influenced by nurture, is active and is staged. Those
supporting this developmental view support a curriculum that
teaches elements of professionalism across the spectrum of
medical education. They note, however, that past research
indicates that often students who come to medical education
possessing desirable attributes leave with a very different
profile:
As they move through their undergraduate medical
education experience, our students also move from
being open-minded to being fact-surfeited, from
being intellectually curious to being increasingly
focused on just that set of knowledge and skills that
must be acquired to pass examinations, from being
open-hearted and empathetic to being emotionally
well-defended, from idealistic to cynical about
medicine, medical practice, and the life of medicine.
(Inui 2003, p. 19)
Correspondence: Anita Duhl Glicken, MSW, University of Colorado Health Sciences Center, Mail Stop F543, Aurora, CO 80045-0508, USA.
Tel: 303-724-1338; fax: 303-724-1350; email: [email protected]
54
ISSN 0142–159X print/ISSN 1466–187X online/07/010054–4 ß 2007 Informa UK Ltd.
DOI: 10.1080/01421590601182602
Educator professionalism
Med Teach Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/23/14
For personal use only.
Practice points
. Current literature continues to document faculty mistreatment of students during medical training impacting
on student attitudes and behaviors.
. While medical professionals share standards of medical
practice in exercising medical knowledge, few have
obtained formal training in the knowledge, skills and
attitudes requisite for teaching excellence. These
standards of educator professionalism are rarely
framed in regard to teacher educators in medical training
programs.
. Educator professionalism overlaps but is distinct from
medical professionalism. Attention needs to be paid to
the professionalization of medical educators as teachers,
a professionalization process that parallels and often
intersects with the values and behaviors of medical
practice but remains a distinct and important body of
knowledge and skills unto itself.
. Enhancing educator professionalism is a critical issue in
educational reform, increasing accountability for meeting student needs. This is based on the underlying
theory that strengthening the educator professional will
prove an effective means for meeting students’ needs
and improving the overall quality of education.
. Assumptions about educator professionalism are subject
to varied interpretation through a personal and cultural
lens, warranting additional dialogue and research as we
move forward to expand definitions and guidelines that
assess and reward the performance of medical
educators.
Previous research on transmission of professional values
offers some explanation for this shift. A study by Stern (1998)
found that a primary reason why medical students are not
learning professional norms is that educators are not
consistently teaching the values of the profession. This was
supported in a study by Burack and colleagues (1999), who
observed responses to unprofessional behavior in medical
teams and documented that attending physicians were reluctant to respond to ‘perceived disrespect, uncaring or hostility
towards patients’. Rather, they avoided or rationalized these
behaviors, failing to address underlying attitudes and values.
We would argue that much of the decline in student
adherence to ideal values, however, is not a result of lapses in
formal curriculum. Most schools now have a course in medical
professionalism and ethics (Makaul 1998) and also offer
extensive programming in patient–provider communication.
An alternative explanation lies in what has been termed ‘the
hidden curriculum’. Several authors would agree that it is the
students’ exposure to what they observe in day-to-day work
with patients and one another that is a far greater influence
than the prescriptions for behavior that are offered in the
classroom. These authors argue that it is the modeling that
students witness that has the most powerful effect on their
professional development (Mathews, 2000; Kenny et al. 2003;
Wright & Carrese, 2003). While these authors stress the
modeling of professional relationships with patients and
colleagues, at times they have fallen short of acknowledging
the importance of the values inherent in the role of the
professional educator. This would include relationships and
concomitant behaviors that stem from the responsibilities of
being an educator based on the expectations of institutional
and societal culture.
We first identified evidence of these lapses in behavior in
our 1990 article entitled ‘Medical student abuse: Incidence,
severity, and significance’ (Silver & Glicken 1990). In this
report on the student population of one major medical school,
46.4% of all respondents stated that they had been abused at
some time while enrolled in medical school, with 80.6% of
seniors reporting being abused by the senior year. More than
two-thirds (69.1%) of those abused reported that at least one of
the episodes they experienced was of ‘major importance and
very upsetting’. Half (49.6%) of the students indicated that the
most serious episode of abuse affected them adversely for a
month or more; 16.2% said that it would ‘always affect them’.
We concluded that medical student abuse was perceived by
these students to be a significant cause of stress and should be
a major concern of those involved with medical student
education. This study was followed by the publication of
numerous other articles attesting to student perceptions of
mistreatment during their medical training. It is important to
note that the incidents of mistreatment identified by students
should not be confused with dissatisfaction due to long work
hours or on-call schedules. These incidents often consisted of
observations of or experiences with unethical behavior, and
experiences of harassment or discrimination (Dougherty et al.
1998). One student related the following: ‘I was examining
another student in an ophthalmology practicum who turned
out to have a corneal abrasion from previous tonometry. As
my classmate was in obvious pain, I wanted to stop the
examination. When I explained this to the supervising
physician he said, ‘‘Oh good, this gives us an opportunity to
learn how to force patient to cooperate even if they are in
pain’’.’ A recent article by Wilkinson et al. (2006) further
documents the serious impact of common adverse events
during medical training.
These experiences are not easily catalogued into the
taxonomies used in educating students for practice; however,
recent efforts, like those of the University of Iowa Carver
College of Medicine and the Association for Surgical Education
(2005) have sought to identify professional behaviors from
residents’ and students’ perspectives using elements of
professionalism and behaviors defined by the ABIM, AAMC
and ACGME to frame resident feedback on faculty professional
behaviors. Although there is clearly overlap between the
learning that prepares one to function as a medical professional and the teaching that occurs in medical institutions, the
dual role of the medical educator as both a medical
professional and an educational professional requires that
we look more closely at the educational literature for
additional insight into factors that impact on the ‘hidden
curriculum’.
This brings us back to the critical point of why this issue of
educator professionalism is so important. A 1992 study by the
United States Department of Education noted that educator
professionalism is a critical issue in education reform. This is
55
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A. D. Glicken & G. B. Merenstein
based on the underlying theory that strengthening the
profession will prove an effective means for meeting students’
needs and improving the overall quality of education. In this
way, educator professionalism promises to increase accountability for meeting student needs. Historically, the primary
focus of the professionalization movement in education has
been discussed in terms of primary and secondary teachers.
Rarely are these standards of professionalism framed with
regard to teacher educators in colleges or medical school
programs. However, the professionalism of all educators is an
important goal. Unlike the primary or secondary educator, the
medical teacher often comes with no preparation or training
in education.
Many notions of professionalism applied to the medical
practitioner are shared by the medical educator. Common
beliefs and behaviors associated with the notion of professionalism in education include that members of a profession
share a common body of knowledge and use shared standards
of practice in exercising their knowledge on behalf of clients.
In addition, professionals strive for practice improvement and
seek enhanced accountability. Professionals create methods
to assure that practitioners will be committed and
competent. ‘Professionals undergo rigorous preparation and
socialization so that the public can have high levels of
confidence that professionals will behave in knowledgeable
and ethical ways.’
While medical professionals share standards of medical
practice in exercising medical knowledge, few have obtained
formal training in the knowledge, skills and attitudes requisite
for teaching excellence. Policies of promotion and tenure offer
some measure of accountability; however, many institutions
reward research and scholarship, while overlooking the merits
or deficits in teaching practice. Few would argue that rigorous
preparation and socialization as an educator is lacking for most
instructors. An argument can be made, therefore, that attention
needs to be paid to the professionalization of medical
educators as teachers, a professionalization process that
parallels and often intersects the values and behaviors of
medical practice but remains a distinct and important body of
knowledge and skills unto itself.
As noted repeatedly in the literature, the concept of
professionalism is multidimensional and complex. The high
level of complexity becomes more apparent, however, as we
briefly explore how these two similar but different bodies of
knowledge, skills and values are similar and different. In their
review of current themes in the literature on medical
professionalism from mid-2002 to 2003, Surdyk and colleagues
(2004) describe the meaning of professionalism in terms of five
types of overlapping relationships, which together support a
systems view of professionalism (Table 1). It could be argued
that these five types of overlapping relationships can be
modified and applied to the medical educator–student and
societal relationships.
At a recent workshop (Faculty Professionalism: The Other
Part of the Hidden Curriculum—AMEE 2005) participants
worked in small groups to identify attributes of student and
medical faculty professionalism. While there was considerable
overlap between these categories and across cultures in areas
such as academic honesty, respect and self-awareness in
practice, other attributes were described only in reference to
faculty. These included qualities such as enthusiasm for their
work, ‘pure’ caring about students, willingness to admit
mistakes and be human, accountability to students, educational institutions and society, and a commitment to lifelong
learning and ongoing improvement of clinical and educational
expertise. These attributes support an adaptation of the model
proposed by Surdyk as depicted in Table 2.
The 25 workshop participants represented 16 countries of
diverse cultural and ethnic background. Although there was
general agreement on desirable attributes and qualities of the
medical educator, the workshop also highlighted the complexity of this issue. For example, a case discussion involving a
medical professor who is observed by a dean and community
member to be having a drink with his students before clinic
was, at face value, considered acceptable in some cultures and
unacceptable in others. Similarly, a faculty member disciplining a student in front of others for what some considered to be
disrespectful behavior in front of a patient was also variably
reviewed, some feeling this was culturally appropriate and,
Table 2. Systems View of Medical Educator Professionalism.
Table 1. Systems View of Professionalism
(Surdyk, P.M., Lynch, D.C., & Leach D.C. 2003).
Relationship
Physician-to-patient
Physician-to-society
relationship
Physician-to-health care
system
interactions between physicians and others
in the health care system
Physician-to-physician
interactions between physicians and their
peers in delivering care and providing
consultations and membership in
professional groups or societies
reflecting on and assessing one’s
own behavior, and taking care of one’s
personal needs
56
Medical educator-to-student
Interaction
interaction between a physician and patient
to foster patient health
the physician’s social contract with society
to be accountable and trustworthy
Physician-to-self
Relationship
Medical educator-to-society
relationship
Medical educator-to-medical
education system
Medical educator-to-educator
Medical educator-to-self
relationship
Interaction
interaction between a medical
educator and student to foster
patient health
the medical educator’s social contract
with society to be accountable and
trustworthy
interactions between medical educators
and others in the medical education
system
interactions between medical educators
and their peers in developing and
promoting excellence in medical
education and consultations and
membership in academic societies
reflecting on and assessing one’s own
behavior, and taking care of one’s
personal and ongoing educational
needs
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Educator professionalism
at times, desirable. This highlighted some of the challenges
to promoting a shared philosophy of professionalism among
colleagues. The group’s shared commitment to medical
educator professionalism was subject to varied interpretation
through a personal and cultural lens that warrants additional
dialogue, particularly as we move forward to expand
definitions and guidelines that assess and reward the
performance of medical educators.
Parker Palmer in his book, The Courage to Teach (1998)
describes a number of ordinary truths about teaching that are
best expressed as paradoxes. Borrowing from these concepts,
the paradox of the medical teacher can be expressed by the
fact that the experience I have gained from 30 years in medical
practice goes hand in hand with my sense of being a rank
amateur in the skills of teaching at the start of every class
I teach or new student I precept. Faculty often come to
medical teaching with the wisdom and experience that dictates
what their students need to know but are often ill-prepared to
know how to communicate that information, skill or attitudinal
set to their students. They often learn the ‘practice’ of education by trial and error from working with their students,
who are often their best teachers. There is no easy fix to the
complex problem of how to change a culture or how to
quickly help faculty become professional educators.
Professional behaviors in teaching and academic relationships,
based on knowledge and values regarding educational roles
and responsibilities, cannot change overnight. Students
are close observers of what faculty do and how they behave
in academic health centers but they also are active recipients
of what faculty think, say and do in their interactions with
students on a daily basis. The culture of the professional
medical educator may need to be viewed simultaneously
through a different lens—that of the professional educator—
whereby we actively work to redefine what is meaningful and
important in our work with our students.
Notes on contributors
ANITA DUHL GLICKEN, MSW, is Professor of Pediatrics, University of
Colorado School of Medicine. She is President of the Physician Assistant
Education Association and Director of the Child Health Associate Physician
Assistant Program.
GERALD B. MERENSTEIN, MD, is Professor of Pediatrics, Medical Director
of the Child Health Associate Physician Assistant Program and formerly
Senior Associate Dean for Education at the University of Colorado School
of Medicine.
References
Accreditation Council for Graduate Medical Education. 1999. ACGME
outcome project: general competencies. Retrieved 24 August 2006
from the World Wide Web:http://www.acge.org/outcome/comp/
compFull.asp
Association for Medical Education in Europe. Amsterdam 2005.
Faculty professionalism: the other part of the hidden curriculum –
pre-conference workshop, August 30, 2005.
Association of American Medical Colleges. 1998. Learning objectives for
medical school education: guidelines for medical schools. Retrieved
24 August 2006 from the World Wide Web: http://aamc.org/meded/
msop
Burack JH, Irby DM, Carline JD, Root RK, Larson EB. 1999. Teaching
compassion and respect: attending physicians’ responses to problematic behaviors. J Gen Intern Med 14:49–55.
Darling-Hammond L, Goodwin AL. 1993. Progress toward professionalism
and teaching, in: G. Cawelti (Ed.) Challenges and Achievements of
American Education: The 1993 ASCD Yearbook, pp. 19–52
(Alexandria, VA, Association for Supervision and Curriculum
Development).
Daugherty S, Baldwin D, Rowley B. 1998. Learning, satisfaction, and
mistreatment during medical internship a national survey of working
conditions. J Amer Med Assoc 279:1194–1199.
Flexner A. 1915. Is Social Work a Profession? (New York, The
New York School of Philanthropy, National Council on Charities and
Corrections).
General Medical Council. 2006. Good medical practice. Retrieved
24 August 2006 from World Wide Web: http://www.gmc-Uk.org/
guidance/good_medical_practice_review/setting_standards_final_
march_06.pdf
Inui T. 2003. A Flag in the Wind: Educating for Professionalism
in Medicine (Washington, DC, Association of American Medical
Colleges).
Kenny NP, Mann KV, Macleod H. 2003. Role modeling in physicians’
professional formation: reconsidering an essential but untapped
educational strategy. Acad Med 78:1203–1210.
Kondro W. 2002. Threats to medical professionalism tackled in Canada.
Lancet 360:316.
Lynch D, Surdyk P, Eiser A. 2004. Assessing professionalism: a review of
the literature. Med Teach 26:366–373.
Makoul G, Curry RH. 1998. Medical school courses in professional skills
and perspectives. Acad Med 73:9–53.
Mann BD, Termuhlen PM, Ujiki M. The Resident, the Student, and the
Competencies: A guide on how to use the competencies as criteria for
evaluating faculty-resident-student interaction. Retrieved 24 August
2006 from the World Wide Web: http://www.facs.org/education/rap/
mann0106.html
Mathews C. 2000. Role modeling: how does it influence teaching in
family medicine? Med Educ 34:443–448.
National Board of Medical Examiners. 2003. Embedding professionalism in
medical education: assessment as a tool for implementation. Retrieved
24 August 2006 from the World Wide Web: http://www.nbme.org/
about/publications.asp
Palmer P. 1998. The Courage to Teach Exploring the Inner Landscape of a
Teacher’s Life (San Francisco, Jossey-Bass).
Rees C. 2005. Proto-professionalism and the three questions about
development. Med Educ 39:7–11.
Royal College of Physicians and Surgeons of Canada. 2005. The CanMEDS
roles framework. Retrieved 24 August 2006 from the World Wide Web:
http://rcpsc.medical.org/canmeds/index.php
Silver HK, Glicken AD. 1990. Medical student abuse. Incidence, severity,
and significance. J Amer Med Assoc 263:527–532.
Stern DT. 1998. Practicing what we preach? An analysis of the curriculum of
values in medical education. Am J Med 104:569–575.
Surdyk P, Lynch D, Leach D. 2003 Professionalism: identifying current
themes. Cur Opin Anaesthesiol 16:597–602.
United States Department of Education. 1995. Systematic reform in the
professionalism of educators. Retrieved 24 August 2006 from the World
Wide Web: http://www.ed.gov/pubs/SER/ProfEd/bkgd.html
Wilkinson TJ, Gill DJ, Fitzjohn J, Palmer CL, Mulder RT. The impact on
students of adverse experiences during medical school. Med Teach
28:129–135.
Wright SM, Carrese JA. 2003. Excellence in role modeling: insights and
perspectives from the pros. Can Med Assoc J 167:638–643.
57
Addressing the hidden curriculum:
Understanding educator professionalism
ANITA DUHL GLICKEN & GERALD B. MERENSTEIN
University of Colorado at Denver and Health Sciences Center, Aurora, USA
Med Teach Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/23/14
For personal use only.
Abstract
Several authors agree that student observations of behaviors are a far greater influence than prescriptions for behavior offered in
the classroom. While these authors stress the importance of modeling of professional relationships with patients and colleagues, at
times they have fallen short of acknowledging the importance of the values inherent in the role of the professional educator. This
includes relationships and concomitant behaviors that stem from the responsibilities of being an educator based on expectations of
institutional and societal culture. While medical professionals share standards of medical practice in exercising medical knowledge,
few have obtained formal training in the knowledge, skills and attitudes requisite for teaching excellence. Attention needs to be
paid to the professionalization of medical educators as teachers, a professionalization process that parallels and often intersects the
values and behaviors of medical practice but remains a distinct and important body of knowledge and skills unto itself. Enhancing
educator professionalism is a critical issue in educational reform, increasing accountability for meeting student needs. Assumptions
regarding educator professionalism are subject to personal and cultural interpretation, warranting additional dialogue and research
as we work to expand definitions and guidelines that assess and reward educator performance.
Over the past five years, several articles and reports have
attempted to identify attributes and themes of medical
professionalism (National Board of Medical Examiners 2003;
Lynch et al. 2004; Surdyk et al. 2004). These papers document
historical attempts to identify strategies to teach and assess
these characteristics in medical professionals and students.
Many of the commonly accepted attributes of professionalism
remain consistent with those identified by Abraham Flexner
(1915) in the early twentieth century in his descriptions of
characteristics of the medical professional. In a recent special
report from the Association of American Medical Colleges, Inui
(2003) cites several taxonomies of domains summarizing
common characteristics associated with professionalism. Lists
include characteristics of altruism, honor and integrity; caring
and compassion; respect; responsibility; accountability; excellence and scholarship; and leadership. Inui notes that these
attributes are jointly endorsed by the American Board of
Internal Medicine (ABIM), the American College of Physicians
and the European Federation of Internal Medicine.
Accreditation bodies also incorporate these characteristics
into their expectations for program curricula. The
Accreditation Council for Graduate Medical Education (1999)
includes professionalism as one of six general competences
required to be taught and assessed in all residence programs
and the Association of American Medical Colleges’ Medical
School Objectives Project (1998) highlights altruism and
dutifulness as associated areas that should be taught in all
medical schools. Similarly, the General Medical Council of the
UK (2006), the Canadian Medical Association (Kondro 2002)
and the CanMeds 2000 Project of the Royal College of
Physicians and Surgeons of Canada (2005) all mandate
professionalism as a priority in medical education and
professional practice.
Many of these endorsements are based on the notion that
physicians ‘develop’ or reform their concept of professionalism
over the course of their education and that various attributes
can be taught, modeled and institutionalized. In a recent
publication Charlotte Rees (2005) describes a model of protoprofessionalism, which assumes that professional development is influenced by nurture, is active and is staged. Those
supporting this developmental view support a curriculum that
teaches elements of professionalism across the spectrum of
medical education. They note, however, that past research
indicates that often students who come to medical education
possessing desirable attributes leave with a very different
profile:
As they move through their undergraduate medical
education experience, our students also move from
being open-minded to being fact-surfeited, from
being intellectually curious to being increasingly
focused on just that set of knowledge and skills that
must be acquired to pass examinations, from being
open-hearted and empathetic to being emotionally
well-defended, from idealistic to cynical about
medicine, medical practice, and the life of medicine.
(Inui 2003, p. 19)
Correspondence: Anita Duhl Glicken, MSW, University of Colorado Health Sciences Center, Mail Stop F543, Aurora, CO 80045-0508, USA.
Tel: 303-724-1338; fax: 303-724-1350; email: [email protected]
54
ISSN 0142–159X print/ISSN 1466–187X online/07/010054–4 ß 2007 Informa UK Ltd.
DOI: 10.1080/01421590601182602
Educator professionalism
Med Teach Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/23/14
For personal use only.
Practice points
. Current literature continues to document faculty mistreatment of students during medical training impacting
on student attitudes and behaviors.
. While medical professionals share standards of medical
practice in exercising medical knowledge, few have
obtained formal training in the knowledge, skills and
attitudes requisite for teaching excellence. These
standards of educator professionalism are rarely
framed in regard to teacher educators in medical training
programs.
. Educator professionalism overlaps but is distinct from
medical professionalism. Attention needs to be paid to
the professionalization of medical educators as teachers,
a professionalization process that parallels and often
intersects with the values and behaviors of medical
practice but remains a distinct and important body of
knowledge and skills unto itself.
. Enhancing educator professionalism is a critical issue in
educational reform, increasing accountability for meeting student needs. This is based on the underlying
theory that strengthening the educator professional will
prove an effective means for meeting students’ needs
and improving the overall quality of education.
. Assumptions about educator professionalism are subject
to varied interpretation through a personal and cultural
lens, warranting additional dialogue and research as we
move forward to expand definitions and guidelines that
assess and reward the performance of medical
educators.
Previous research on transmission of professional values
offers some explanation for this shift. A study by Stern (1998)
found that a primary reason why medical students are not
learning professional norms is that educators are not
consistently teaching the values of the profession. This was
supported in a study by Burack and colleagues (1999), who
observed responses to unprofessional behavior in medical
teams and documented that attending physicians were reluctant to respond to ‘perceived disrespect, uncaring or hostility
towards patients’. Rather, they avoided or rationalized these
behaviors, failing to address underlying attitudes and values.
We would argue that much of the decline in student
adherence to ideal values, however, is not a result of lapses in
formal curriculum. Most schools now have a course in medical
professionalism and ethics (Makaul 1998) and also offer
extensive programming in patient–provider communication.
An alternative explanation lies in what has been termed ‘the
hidden curriculum’. Several authors would agree that it is the
students’ exposure to what they observe in day-to-day work
with patients and one another that is a far greater influence
than the prescriptions for behavior that are offered in the
classroom. These authors argue that it is the modeling that
students witness that has the most powerful effect on their
professional development (Mathews, 2000; Kenny et al. 2003;
Wright & Carrese, 2003). While these authors stress the
modeling of professional relationships with patients and
colleagues, at times they have fallen short of acknowledging
the importance of the values inherent in the role of the
professional educator. This would include relationships and
concomitant behaviors that stem from the responsibilities of
being an educator based on the expectations of institutional
and societal culture.
We first identified evidence of these lapses in behavior in
our 1990 article entitled ‘Medical student abuse: Incidence,
severity, and significance’ (Silver & Glicken 1990). In this
report on the student population of one major medical school,
46.4% of all respondents stated that they had been abused at
some time while enrolled in medical school, with 80.6% of
seniors reporting being abused by the senior year. More than
two-thirds (69.1%) of those abused reported that at least one of
the episodes they experienced was of ‘major importance and
very upsetting’. Half (49.6%) of the students indicated that the
most serious episode of abuse affected them adversely for a
month or more; 16.2% said that it would ‘always affect them’.
We concluded that medical student abuse was perceived by
these students to be a significant cause of stress and should be
a major concern of those involved with medical student
education. This study was followed by the publication of
numerous other articles attesting to student perceptions of
mistreatment during their medical training. It is important to
note that the incidents of mistreatment identified by students
should not be confused with dissatisfaction due to long work
hours or on-call schedules. These incidents often consisted of
observations of or experiences with unethical behavior, and
experiences of harassment or discrimination (Dougherty et al.
1998). One student related the following: ‘I was examining
another student in an ophthalmology practicum who turned
out to have a corneal abrasion from previous tonometry. As
my classmate was in obvious pain, I wanted to stop the
examination. When I explained this to the supervising
physician he said, ‘‘Oh good, this gives us an opportunity to
learn how to force patient to cooperate even if they are in
pain’’.’ A recent article by Wilkinson et al. (2006) further
documents the serious impact of common adverse events
during medical training.
These experiences are not easily catalogued into the
taxonomies used in educating students for practice; however,
recent efforts, like those of the University of Iowa Carver
College of Medicine and the Association for Surgical Education
(2005) have sought to identify professional behaviors from
residents’ and students’ perspectives using elements of
professionalism and behaviors defined by the ABIM, AAMC
and ACGME to frame resident feedback on faculty professional
behaviors. Although there is clearly overlap between the
learning that prepares one to function as a medical professional and the teaching that occurs in medical institutions, the
dual role of the medical educator as both a medical
professional and an educational professional requires that
we look more closely at the educational literature for
additional insight into factors that impact on the ‘hidden
curriculum’.
This brings us back to the critical point of why this issue of
educator professionalism is so important. A 1992 study by the
United States Department of Education noted that educator
professionalism is a critical issue in education reform. This is
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A. D. Glicken & G. B. Merenstein
based on the underlying theory that strengthening the
profession will prove an effective means for meeting students’
needs and improving the overall quality of education. In this
way, educator professionalism promises to increase accountability for meeting student needs. Historically, the primary
focus of the professionalization movement in education has
been discussed in terms of primary and secondary teachers.
Rarely are these standards of professionalism framed with
regard to teacher educators in colleges or medical school
programs. However, the professionalism of all educators is an
important goal. Unlike the primary or secondary educator, the
medical teacher often comes with no preparation or training
in education.
Many notions of professionalism applied to the medical
practitioner are shared by the medical educator. Common
beliefs and behaviors associated with the notion of professionalism in education include that members of a profession
share a common body of knowledge and use shared standards
of practice in exercising their knowledge on behalf of clients.
In addition, professionals strive for practice improvement and
seek enhanced accountability. Professionals create methods
to assure that practitioners will be committed and
competent. ‘Professionals undergo rigorous preparation and
socialization so that the public can have high levels of
confidence that professionals will behave in knowledgeable
and ethical ways.’
While medical professionals share standards of medical
practice in exercising medical knowledge, few have obtained
formal training in the knowledge, skills and attitudes requisite
for teaching excellence. Policies of promotion and tenure offer
some measure of accountability; however, many institutions
reward research and scholarship, while overlooking the merits
or deficits in teaching practice. Few would argue that rigorous
preparation and socialization as an educator is lacking for most
instructors. An argument can be made, therefore, that attention
needs to be paid to the professionalization of medical
educators as teachers, a professionalization process that
parallels and often intersects the values and behaviors of
medical practice but remains a distinct and important body of
knowledge and skills unto itself.
As noted repeatedly in the literature, the concept of
professionalism is multidimensional and complex. The high
level of complexity becomes more apparent, however, as we
briefly explore how these two similar but different bodies of
knowledge, skills and values are similar and different. In their
review of current themes in the literature on medical
professionalism from mid-2002 to 2003, Surdyk and colleagues
(2004) describe the meaning of professionalism in terms of five
types of overlapping relationships, which together support a
systems view of professionalism (Table 1). It could be argued
that these five types of overlapping relationships can be
modified and applied to the medical educator–student and
societal relationships.
At a recent workshop (Faculty Professionalism: The Other
Part of the Hidden Curriculum—AMEE 2005) participants
worked in small groups to identify attributes of student and
medical faculty professionalism. While there was considerable
overlap between these categories and across cultures in areas
such as academic honesty, respect and self-awareness in
practice, other attributes were described only in reference to
faculty. These included qualities such as enthusiasm for their
work, ‘pure’ caring about students, willingness to admit
mistakes and be human, accountability to students, educational institutions and society, and a commitment to lifelong
learning and ongoing improvement of clinical and educational
expertise. These attributes support an adaptation of the model
proposed by Surdyk as depicted in Table 2.
The 25 workshop participants represented 16 countries of
diverse cultural and ethnic background. Although there was
general agreement on desirable attributes and qualities of the
medical educator, the workshop also highlighted the complexity of this issue. For example, a case discussion involving a
medical professor who is observed by a dean and community
member to be having a drink with his students before clinic
was, at face value, considered acceptable in some cultures and
unacceptable in others. Similarly, a faculty member disciplining a student in front of others for what some considered to be
disrespectful behavior in front of a patient was also variably
reviewed, some feeling this was culturally appropriate and,
Table 2. Systems View of Medical Educator Professionalism.
Table 1. Systems View of Professionalism
(Surdyk, P.M., Lynch, D.C., & Leach D.C. 2003).
Relationship
Physician-to-patient
Physician-to-society
relationship
Physician-to-health care
system
interactions between physicians and others
in the health care system
Physician-to-physician
interactions between physicians and their
peers in delivering care and providing
consultations and membership in
professional groups or societies
reflecting on and assessing one’s
own behavior, and taking care of one’s
personal needs
56
Medical educator-to-student
Interaction
interaction between a physician and patient
to foster patient health
the physician’s social contract with society
to be accountable and trustworthy
Physician-to-self
Relationship
Medical educator-to-society
relationship
Medical educator-to-medical
education system
Medical educator-to-educator
Medical educator-to-self
relationship
Interaction
interaction between a medical
educator and student to foster
patient health
the medical educator’s social contract
with society to be accountable and
trustworthy
interactions between medical educators
and others in the medical education
system
interactions between medical educators
and their peers in developing and
promoting excellence in medical
education and consultations and
membership in academic societies
reflecting on and assessing one’s own
behavior, and taking care of one’s
personal and ongoing educational
needs
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Educator professionalism
at times, desirable. This highlighted some of the challenges
to promoting a shared philosophy of professionalism among
colleagues. The group’s shared commitment to medical
educator professionalism was subject to varied interpretation
through a personal and cultural lens that warrants additional
dialogue, particularly as we move forward to expand
definitions and guidelines that assess and reward the
performance of medical educators.
Parker Palmer in his book, The Courage to Teach (1998)
describes a number of ordinary truths about teaching that are
best expressed as paradoxes. Borrowing from these concepts,
the paradox of the medical teacher can be expressed by the
fact that the experience I have gained from 30 years in medical
practice goes hand in hand with my sense of being a rank
amateur in the skills of teaching at the start of every class
I teach or new student I precept. Faculty often come to
medical teaching with the wisdom and experience that dictates
what their students need to know but are often ill-prepared to
know how to communicate that information, skill or attitudinal
set to their students. They often learn the ‘practice’ of education by trial and error from working with their students,
who are often their best teachers. There is no easy fix to the
complex problem of how to change a culture or how to
quickly help faculty become professional educators.
Professional behaviors in teaching and academic relationships,
based on knowledge and values regarding educational roles
and responsibilities, cannot change overnight. Students
are close observers of what faculty do and how they behave
in academic health centers but they also are active recipients
of what faculty think, say and do in their interactions with
students on a daily basis. The culture of the professional
medical educator may need to be viewed simultaneously
through a different lens—that of the professional educator—
whereby we actively work to redefine what is meaningful and
important in our work with our students.
Notes on contributors
ANITA DUHL GLICKEN, MSW, is Professor of Pediatrics, University of
Colorado School of Medicine. She is President of the Physician Assistant
Education Association and Director of the Child Health Associate Physician
Assistant Program.
GERALD B. MERENSTEIN, MD, is Professor of Pediatrics, Medical Director
of the Child Health Associate Physician Assistant Program and formerly
Senior Associate Dean for Education at the University of Colorado School
of Medicine.
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