Acad Psychiatry 31:354-357, September-October 2007
doi: 10.1176/appi.ap.31.5.354
© 2007 Academic Psychiatry
Virtues-Based Advice for Beginning Medical Students
John H. Coverdale, M.D., M.Ed., F.R.A.N.Z.C.P.
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ABSTRACT
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OBJECTIVE: The goals of this article are to present a framework, based on John Gregory’s (1724–1773) concept of professionalism, for advising beginning medical students about what is important to training and to the practice of medicine. METHOD: The author presents Gregory’s concept of professionalism with an emphasis on the related virtues. Members of the editorial board of Academic Psychiatry were also surveyed for their advice for beginning students. RESULTS: There are four fundamental virtues that originated from Greogory’s concept of professionalism: integrity, compassion, self-effacement, and self-sacrifice. Medical students should actively cultivate these virtues in order to promote excellence in every clinical encounter. CONCLUSIONS: These four fundamental virtues together obligate medical students to learn and practice in accordance with the principles of evidence-based medicine and to protect and promote the interests of patients.
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INTRODUCTION
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The first day of medical school is one of the most exciting in a medical career. It is both a celebration of earlier achievements and a new start with unimaginable adventures and fun ahead. What should beginning medical students know or be advised about how to approach the training ahead?
MEDLINE searching with terms such as "advice to medical students" or "convocation lecture" provided limited guidance (1, 2). I was aware, however, of a collection of thoughts for beginning medical students by Richard Smith, the immediate past editor of the British Medical Journal (3). Smith began with reference to D. W. Winnicott’s concept of the "good enough mother" (4) to argue that students should appreciate that there is only one who is best, that we cannot all be the best, and that being good enough as a physician is a worthy goal. Students should accept their own limitations and liberally use the "three most important words": "I don’t know." He also advised that students and physicians not conform to pressures to become a stereotypical doctor or to spend their lifetime becoming something they are not.
Smith had asked members of his own editorial board for advice about what to say. Because any advice I might give to students would be meager, I chose to adopt this method by writing to members of the editorial board of Academic Psychiatry for their advice. I asked, for example, what would they have wanted to know that they didn’t know as a beginning medical student. I received an enthusiastic response that included some speeches, pearls of wisdom, favored articles (5–7), and a book recommendation (8).
One goal for this article, therefore, is to present a definition of professionalism with an emphasis on the concept of fiduciary and on the virtues that follow (9). This will serve as a framework for advising medical students about what is important to training in particular and to their future medical practice. A second goal is to convey the advice provided by members of the editorial board of Academic Psychiatry to beginning medical students. Their comments are separated from the main text and italicized as exampled by the three introductory comments below. As Smith noted (3), giving advice to medical students makes all of us think about what is important in what we do.
"Your path, medicine’s path, and the path of others in your life will be nothing like what you expect."
"Conceivably, you could become a cardiac surgeon, a medical center administrator, a devoted teacher, a textbook author, an international public health worker, or a private practicing dermatologist."
"You cannot know how lucky you are to be embarking on the greatest career possible, to be entrusted with life and death matters, and the most intimate details of the lives of patients you will care for."
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Gregory’s Professionalism
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The road ahead, while certainly exciting, is also undeniably challenging. Medical school is unlike college in that students’ responsibility shifts towards taking care of patients, and learning occurs with that purpose in mind. Some patients evoke powerful and distressing emotions—dealing with death and disability is uncomfortable at best—and we risk unintentionally harming patients that we intend to benefit. Resolve and emotional fortitude will be tested. Complex ethical decisions include how to address potential conflicts of interest concerning payments or gifts and concerning relationships to the health care industry (10, 11), and between physicians’ own interests and needs and those of patients.
The concept of professionalism (Appendix 1) and the related professional virtues are central to the disciplined practice of medicine in the face of these pressures. This concept, which did not originate from the Hippocratic Oath, was "invented" (9, 12) by John Gregory (1724–1773). John Gregory is a less well-appreciated figure in the history of medicine who heavily influenced Thomas Percival (1740–1804), who in turn was a major contributor to the Code of Ethics of the American Medical Association of 1847 (12). I am indebted to my colleague, Dr. Laurence McCullough, for the following account (9, 12, 13).
Gregory practiced in 18th century Scotland at a time when there was great competition in the marketplace between physicians, no uniform pathway to becoming a physician, and an unlimited number of concepts of health and disease. Some physicians put on "good manners" in order to pry their way into the houses of the rich, and to take advantage of the trust and confidences of the sick. Some also became sexual predators of the sick. Gregory was concerned with both a lack of scientific competence and rampant self-interest; physicians were not trusted to put the interests of the sick ahead of their own (9, 12, 13).
Gregory appealed to Francis Bacon (1561–1626) in addressing the problem of competence by calling on medicine to be based on experience or on the rigorously collected results of natural and designed experiments. This concept of reliance on evidence, now called evidence-based medicine, constitutes the first component of the concept of fiduciary. Physicians who practice in accordance with these standards enable patients to trust physicians intellectually. Gregory warned us against obstinate adherence to unsuccessful methods of treating disease "to which species of pride, a pride incompatible with true dignity and elevation of mind, have the lives of thousands been sacrificed" (9). Consequently, and given the context of the editorial board member’s comment below, medical students need to learn how to stay current with scientific advances, to question, even to learn to doubt (3), and how to find the best answers.
"By the time you graduate from medical school, the knowledge you have learned will be dated."
The second and third components of Gregory’s professionalism direct the physicians’ attention away from oneself to the needs and interests of the patient (12). When physicians focus on the needs of patients and not on their own self-interest, patients can trust physicians morally. The virtues, as we shall see, give form to these two components of fiduciary and together provide a starting point for the moral or ethical practice of medicine.
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Cultivating the Virtues
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As is shown in Appendix 2, there are four fundamental virtues originating from John Gregory’s concept of professionalism, the most important of which is integrity. Integrity commits physicians to a lifelong pursuit of excellence in the care of patients. Compassion, which follows Gregory and Hume’s account of sympathy (13), moves physicians to protect and promote the interests of patients through identification with their suffering. Self-effacement reduces the potential that differences between the physician and patient in social class, appearance, ethnicity, religion, and beliefs will adversely affect the physician-patient relationship. Percival (12), for example, argued that patients from lower socioeconomic classes (the public patients of today) should not be treated as inferior but should be regarded as (especially) worthy. Self-sacrifice concerns the routine willingness of physicians to make sacrifices in their own lives in order to advance the interests of patients.
"Harness the power inherent from your position into interventions that will serve the patients’ needs."
Cultivating the virtues is an active and daily process that requires thoughtful self-reflection and keen appreciation of motivation as a first step towards self-correction. It starts with medical students and physicians as individuals but also applies to wider medical organizations, which, unlike corporations, have fiduciary obligations to patients. As indicated by an editorial board member below, we should thus appreciate this history, and also promote the fiduciary responsibilities of the medical organizations to which we belong.
"It is very moving to remember you are entering an ancient fraternity of healing and not joining a new corporation."
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Implications of the Virtues for Medical Training
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How do the virtues apply to the challenge of managing potential adversities in training and practice? First, integrity obligates students to try to maximize educational opportunities in order to be better prepared to treat prospective patients. In addition, students are responsible to bring their best efforts to every patient encounter. Concomitantly, integrity obligates teachers to inform about evidence-based practices and to role model respect for patients and other professionals.
Second, integrity obligates medical students and physicians to promote the work of our colleagues and peers. Much of medicine is practiced in teams and high performance learning teams almost always outperform the best individual in the team (14). Therefore, optimizing team processes, such as collegiality, communication, leadership, and competition, supports excellence in the clinical practice of medicine.
"Learn the importance of working with teams and to respect all disciplines."
"Take a look at the person next to you. By graduation he or she will be your dearest friend."
Third, self-effacement and self-sacrifice in particular prevent the possibility that clinical judgment will become unhinged by the sometimes powerful feelings evoked by patients. Feelings of frustration, foreboding for concern that patients will place themselves at undue risk by their behaviors, displeasure, discomfort, or even sexual feelings (15) can result in a loss of focus. These feelings should at first be acknowledged when present (16) and, as indicated by an editorial board member’s comment below, mentorship is one response that prevents these feelings from distorting clinical judgment. Recognizing bias in judgments supports principled action with compassion (7).
"Seek mentorship. Mentors can prevent students from getting mired in day-to-day frustrations, and can provide history, context, and perspective."
Fourth, contributing to the advancement of knowledge provides one method for meeting our fiduciary obligations to patients. Learning to question and to develop and test hypotheses is integral to learning in medicine. Tremendous rewards follow from working a research question through to publication (17).
Fifth, the virtues blunt but do not eliminate self-interest. Physicians should ensure balance in their lives by appreciating that they have obligations not just to patients but to themselves, their families, and friends. Achieving an adequate balance is reinvigorating and promotes compassion.
"Take care of yourself; students should learn about making time for their families. Get enough sleep and do not drink in excess."
"At the end of the day it will be friendships, even more than the Kreb’s Cycle, that will be remembered."
This focus on the virtues, as habits or traits of character (9, 12, 13), underscores the importance of personality in the practice of medicine.
"The most powerful tool you have is you."
How physicians care for patients in the level of personal support provided, and how they bear witness to patients’ pain, could be as important as what physicians know (5). Patients, after all, may not remember what was done for them, nor what was said, but they do not forget how they were made to feel (18). Similarly, should physicians fail, it is less likely because of what they do not know, but more likely because of their personality, including their trustworthiness (19). Therefore, as formerly counseled (19), physicians should work conscientiously to improve their level of maturity and to cultivate the virtues.
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Conclusions
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As indicated below by the comments from the editorial board, there is reason for tremendous enthusiasm and optimism.
"Medicine will be completely different when you are in our shoes, except for the fundamentally wonderful awe-inspiring exchange between two people who are both changed by the encounter."
"The best part of being a doctor is the ability to listen to what patients have to say, to understand it, and to offer relief through compassion, knowledge, and humanity."
As teachers, it is an honor and privilege indeed to play a small part in contributing to the education of medical students. We look to all students with enormous respect, hope and anticipation for the future. And, the more things change, the more they stay the same. Although knowledge and skill-based advances will allow for unforeseeable treatments in the future, the importance of every single interaction with patients will not be diminished. Cultivating the virtues, learning to listen to patients’ stories, and appreciating the power of words and behavior in every encounter will endure as essential to the practice of medicine.
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ACKNOWLEDGMENTS
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This article is based on the convocation lecture presented to the incoming medical students at Baylor College of Medicine on July 26, 2006. The author gratefully acknowledges the contributions of each of the members of Academic Psychiatry’s editorial board of June 2006. The author also gratefully acknowledges the guidance of and contributions to this paper by Laurence McCullough, Ph.D.
Dr. Coverdale is Associate Editor of the Journal. Manuscripts that are authored by an Editor of Academic Psychiatry or a member of the Editorial Board undergo the same editorial review process applied to all manuscripts, including blinded peer review. Additionally, the Editor is recused from any editorial decision-making.
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REFERENCES
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- Tips and advice by medical students for new and incoming medical students. http://md.com/medstudenttips.shtml
- Tips on medical student well being. http://www.amsa.org/humed/survival.cfm
- Smith R: Thoughts for new medical students at a new medical school. BMJ 2003; 327:1430–1433[Free Full Text]
- Winnicott DW: Transitional objects and transitional phenomena; a study of the first not-me possession. Int J Psychoanal 1953; 34:89–92[Medline]
- Treadway K: Notes to the class: first day. N Engl J Med 2005; 352:1943–1944[Free Full Text]
- Sobel RK MSL: Medicine as a second language. N Engl J Med 2005; 352:1945–1946[Free Full Text]
- Epstein RM: Mindful practice JAMA 1999; 282:833–839
- Ofri D: Singular Intimacies: Becoming a Doctor at Bellevue. Boston, Beacon Press, 2003
- McCullough LB: John Gregory (1724-1773) and the Invention of Professional Medical Ethics and the Profession of Medicine. Dordrecht, The Netherlands, Kluwer Academic, 1998
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- Brennan TA, Rothman DJ, Blank L, et al: Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA 2006: 295:429-433
- McCullough LB, Chervenak FA: Ethics in Obstetrics and Gynecology. New York, Oxford University Press, 1994
- McCullough LB: John Gregory (1724-1773) and the invention of professional relationships in medicine. J Clin Ethics 1997; 8:11–21[Medline]
- Michaelsen LK, Knight AB, Fink LD: Team-Based Learning: A Transformative Use of Small Groups. Westport, Conn, Greenwood, 2002
- McCullough LB, Chervenak FA, Coverdale J: Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients. Am J Obstetr Gynecol 1996; 175:496–500[CrossRef][Medline]
- Gorlin R, Zucker HD: Physicians reactions to patients: a key to teaching humanistic medicine. N Engl J Med 1983; 308:1059–1063[Medline]
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- Duff P: Dear graduate. Obstetr Gynecol 2006; 107:1411–1412[CrossRef][Medline]
This article has been cited by other articles:
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J. H. Coverdale, L. Weiss Roberts, and A. K. Louie
Teaching Evidence-Based Psychiatry to Residents and Fellows: Developing the Curriculum
Acad Psychiatry,
November 1, 2008;
32(6):
453 - 457.
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ABSTRACT
INTRODUCTION
