EDITORIAL
of the authors and THE JOURNAL and not those of
Instilling Professionalism in Medical Education
Kenneth M. Ludmerer, MD
P
ROFESSIONS HAVE LONG BEEN RECOGNIZED TO CON-
sist of 3 essential characteristics: expert knowl-
edge (as distinguished from a practical skill), self-
regulation, and a fiduciary responsibility to place
the needs of the client ahead of the self-interest of the prac-
titioner.1 In recent years there has been renewed recogni-
tion among medical leaders of the particular importance of
the third, or altruistic, characteristic in medical profession-
alism.2-4 For instance, in 1994 the American Board of In-
ternal Medicine defined the “core of professionalism” as “con-
stituting those attitudes and behaviors that serve to maintain
patient interest above physician self-interest.”4
In recent years, market forces have posed an unprec-
edented threat to medical professionalism—particularly the
physician’s obligation to serve the needs of patients. For all
its defects, the fee-for-service system that long dominated
medicine had one great advantage: it allowed physicians eas-
ily to do what was necessary for patients. In contrast, today’s
managed care environment has undermined physicians’ abil-
ity to provide patients with needed care. Many managed care
organizations, whether seeking to control costs or maxi-
mize profits, have created strong financial incentives for phy-
sicians to restrict care.5 Some managed care organizations have
even urged that physicians be taught to act in part as advo-
cates of the insurance payer rather than the patients for whom
they care.6 This has caused some critics to raise the specter
of physicians becoming “double agents” who would purport-
edly serve the patient but in fact limit care for the financial
benefit of the employing organization.7
In this context, the article by Swick and colleagues8 in
this issue of THE JOURNAL is timely and encouraging. Of the
116 US medical schools that responded to their survey, 104
reported that they offer some type of formal instruction re-
lated to professionalism. The nature of this instruction var-
ied widely, from a single “white coat” ceremony for ma-
triculating students to a component of 1 or multiple courses.
Most of the instruction occurs during the first 2 years of medi-
cal school. The authors emphasize that current strategies
to teach professionalism need to be enhanced, as do meth-
ods for assessing educational outcomes. However, the study
See also pp 830 and 833.
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Editorials represent the opinions
the American Medical Association.
does document that at this critical time in American medi-
cine, most medical schools acknowledge the need to ad-
dress professionalism as an essential element of the educa-
tion of their students.
Are formal courses sufficient to instill a sense of profes-
sionalism among medical students? In another article in this
issue of THE JOURNAL, Epstein9 argues that they are not. Ep-
stein’s article invokes concepts from cognitive science, phi-
losophy, and adult learning theory to describe a state of
awareness he calls “mindfulness.” In Epstein’s view, the
“mindful” physician possesses the mental qualities neces-
sary for both good clinical decision making and proper pro-
fessional behavior. What is especially notable is the au-
thor’s contention that the cultivation of mindfulness requires
mentoring and guidance, not formal course work. Accord-
ing to Epstein, “[E]ach of us can identify practitioners who
embody these attributes, learn from them, and identify unique
ways of being self-aware. Educators can take on the task of
helping trainees become more mindful by explicitly mod-
eling their means for cultivating awareness.”
Formal studies assessing the relative influence of didac-
tic teaching and role-modeling on the development of pro-
fessional values have not been conducted. However, there
is reason to believe that both approaches are important, just
as environment and heredity both influence the phenotype
of living organisms. A number of concepts from history, the
social sciences, and the humanities are central to under-
standing and internalizing professionalism.10 However, em-
pirical evidence that formal instruction alone enhances pro-
fessionalism is lacking.
For more than 30 years, public charges that physicians
are impersonal, self-serving, greedy, and occasionally dis-
honest have been increasing—despite the expanded teach-
ing of the medical humanities and ethics at medical schools
during this period. (Similarly, there is no evidence that the
introduction of ethics courses in business schools in the 1980s
and 1990s has produced more ethical behavior among busi-
ness executives.) Sociologists have criticized medical edu-
cators—and educators in general—for their commonly held
belief that formal course work can serve as “intellectual magic
bullets” to shape human attitudes and behavior.11 Such crit-
Author Affiliation: Department of Medicine, Washington University, St Louis, Mo.
Corresponding Author and Reprints: Kenneth M. Ludmerer, MD, Department of
Medicine, Washington University, 660 S Euclid Ave, St Louis, MO 63110 (e-mail:
kludmere@im.wustl.edu).
JAMA, September 1, 1999—Vol 282, No. 9 881
 EDITORIAL
ics remind us, as Epstein does in his article, that values are
absorbed from role models as well as learned from didactic
teaching.
The main limitation of both the instructional and men-
toring approaches is that even when offered together, these
account for only some of the factors that influence the de-
velopment of professionalism. Numerous sociological stud-
ies over the past 4 decades have documented the profound
impact of the entire institutional environment of the aca-
demic health center on shaping the attitudes, values, be-
liefs, modes of thought, and behavior of medical stu-
dents.12 In this broad view of the professionalization process,
attitudes are shaped by the totality of students’ interactions
with faculty, house officers, patients, hospital staff, and one
another in laboratories, classrooms, wards, and clinics. For-
mal course work and mentoring represent only 2 of the many
factors that affect the development of attitudes. An un-
friendly institutional culture can easily undermine the well-
intentioned efforts of those trying to impart professional-
ism through means of the curriculum. Thus, the effect of a
brilliant lecture to the assembled medical class on the im-
portance of caring for the patient can easily be undone should
the student return to the ward and hear the resident speak
of the “GOMER” who was just admitted.
In this context, the greatest challenge in improving the
teaching of professionalism is to modify the internal cul-
ture of the academic health center so that it better rein-
forces the values that medical educators wish to impart. At
present this represents no small task, for the managed care
revolution has caused medical schools and teaching hospi-
tals to become much less friendly to patients and students
than they were even a few years ago. The imperative to maxi-
mize throughput (to see large numbers of patients quickly)
has diminished the personal contact between faculty and stu-
dents,10,13 contributed to a deterioration of bedside clinical
skills,14 demoralized many faculty,10 and possibly had a del-
eterious impact on the quality of care provided.10 The em-
phasis on throughput has also caused a marked erosion of
the clinical learning environment, particularly by reducing
the time available for teachers to teach and students to learn.10
Medical educators would do well to ponder the potential
long-term consequences of educating the nation’s physi-
cians in today’s commercial atmosphere in which the good
visit is a short visit, patients are “consumers,” and institu-
tional officials speak more often of the financial balance sheet
882 JAMA, September 1, 1999—Vol 282, No. 9
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than of service and the relief of patients’ suffering. Such an
environment does little to validate the altruism and ideal-
ism that students typically bring with them to the study of
medicine.
Ultimately, a broad-based approach to instilling profes-
sionalism is likely to be most effective. Such an approach
includes attention to formal teaching and faculty mentor-
ing. However, it also involves working to make the inter-
nal culture of academic health centers less commercial and
more service oriented. This larger task will not be easily ac-
complished because the commercial forces presently affect-
ing academic health centers are strong and not every factor
is under the direct control or influence of medical facul-
ties. Nevertheless, there is reason to hope that the task can
be achieved—provided that medical leaders have the cour-
age to address the structural problems confronting medi-
cal education and practice directly and are willing to stand
up for the interests of patients and the public.1,10 Society,
patients, and the medical profession will be well served by
such an effort.
Funding/Support: This work has been supported in part by a grant from the Charles
E. Culpeper Foundation.
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©1999 American Medical Association. All rights reserved.