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Positive Approaches to Affirming Professionalism in Medical Education

Lynda G. Montgomery, MD, MEd, Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine

Lesser and colleagues used Aristotle’s words, “Excellence is not an act, but a habit” as an epigram to their 2010 call for more explicit acknowledgement of the dynamic nature of professional behaviors in medicine. While the overarching notion is centuries old, calls to address lapses in professional behavior with a systems-based approach are just gaining traction in medical education literature.1,2

Medical education scholars have firmly established the role of informal and hidden curriculum in shaping the professional identities of students. We, as a community of educators, are moving toward consensus that professionalism is not a trait but rather is a dynamic state that is demonstrated by observable behaviors. The organizational culture of health systems is of paramount importance since this is the context in which our students learn the informal curriculum.3,4

All physicians, including student physicians, can begin to modify their professional behavior and enact their values when we, as an organizational culture in health care, believe that professionalism is demonstrated by our actions. Labeling an individual as being “professional” (or not) ignores the complex challenges and opportunities that clinical work provides. Further, models that use positive approaches to build leadership skills have shown success in a variety of settings, including health care and medical education.

Appreciative inquiry is an approach to understand what works well among systems, people, and the world around them.5 Very briefly, the appreciative inquiry model has organizations focus on “What’s working well?” rather than “What are the problems and deficiencies?” Since its development at Case Western Reserve University by researchers in the Department of Organizational Behavior in the 1980s, appreciative approaches and related positive models of organizational development have been used in health care and medical education settings.6 Similarly, mindful communication education has been used with individual physicians to improve their ability to perform at their best.7 Both approaches seek to “catch people at their best” and to tell and re-tell stories of success. These positive narrative approaches can have tangible impacts on workplace cultures and outcomes.

By teaching our learners appreciative approaches to leadership and skills, students can begin to shift the culture away from highly stressed transient health care teams where professional behavior can vary in quality. Educators can use an appreciative inquiry approach to elicit stories from peers and students demonstrating core principles of professionalism, then bring these stories back to clinical teams to highlight successes and reinforce what is already working well.Asking learners to identify strengths in themselves and the health care team can enhance self-regulation of professional behaviors. Practicing these skills in routine clinical situations may prepare students to apply these approaches when values conflicts arise.8 Use of the appreciative inquiry model can help learners develop the capability to enact the core principles of our profession.

1. Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304(24):2732-7.
2. Lucey C, Souba W. The problem with the problem of professionalism. Acad Med 2010;85(6):1018-24.
3. Stern DT, Papadakis M. The developing physician—becoming a professional. N Engl J Med 2006;355:1794-9.
4. Karniell-Miller O, Vu TR, Holtman MC, Clyman SG, Inuit S. Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Acad Med 2010;85(1):124-33.
5. http://appreciativeinquiry.case.edu. Accessed May 14, 2013.
6. Suchman A, Williamson PR, Litzelman DK, et al. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med 2004;19(5, Pt. 2):501-4.
7. Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Acad Med 2012;87(6):815-9.
8. Quaintance JL, Arnold L, Thompson GS. What students learn about professionalism from faculty stories: an “appreciative inquiry” approach. Acad Med 2010;85(1):118-23.

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