‘Knowledge is important, but more important is the use towards which it is put. This depends on the heart and mind of the one who uses it’1
SUMMARY
One element of a good doctor is that of being a kind, considerate and honourable professional practitioner. These features of a ‘good person’ are enshrined in a German–Jewish concept of being a ‘mensch’, a term that could describe some of the attributes of a good doctor, although other cultures may have equivalent concepts.
We will discuss the argument for role modelling, empathy, reflective practice, and some of the virtues inherent in good UK General Practice to be a principle of education for undergraduate medical students. GPs are trained to view patients holistically and are important members of their local communities, so this is a suitable role for general practice within the undergraduate medical curriculum. Good GPs may be able to act as role models and to provide the basis for a discussion on their professional role with real patients in the real world.
INTRODUCTION
Most undergraduate medical education takes place within higher education institutions, although increasingly more teaching takes place with GPs in their own surgeries.2
Students have commented that much of their teaching in hospital is postponed, cancelled or rushed,3 and their teaching experiences may be rather more passive than they might like.4 Further, teaching is relatively undervalued by busy clinicians, and clinical teaching is often a neglected activity.5
All clinical teaching sessions provide opportunities for students to discuss ‘real world medicine’ with interested practitioners. When students attend their GP placements, there are opportunities for the GP teacher to act as role model, mentor, and supportive guide. A creative GP teacher can have a discussion with students about professionalism and both the techniques and the spirit of how to be a kind, thoughtful and honourable professional.
We suggest that a suitable place to start these discussions is with a potentially idealised person, and in this context we introduce the concept of the ‘mensch’. In German–Jewish culture a ‘mensch’ is somebody who acts nobly, wisely and with honour. The role of the mensch is to provide wise counsel at times of trouble, and to know when to listen and when to make practical, feasible suggestions. Most communities are aware of a person who fulfils such a role: the person may be a friend, a lay person, or a professional person, but in any instance they act from noble, impartial motives.
GPS AND TEACHING
This article will mostly be read by GPs. Therefore, this need only be a brief section on why general practice is an admirable venue to discuss issues of integrity and professionalism with students. GPs are used to acting within communities and are aware of the roles of family and community in holistic health care.6
This places GPs in a unique position to perform appropriate community-based primary medical care for individuals, families and communities in their clinical practice as a matter of course. It is inevitable that there will be issues of ethical principles and reasoning that take place during any GP's normal working day, so much so that many GPs may be almost unaware of behaving in an appropriately ethical manner.
GPs provide good clinical teaching within their practice.7 Tutors can benefit from the experience too,8 and many students enjoy receiving good teaching from their GP teachers.9 Teaching in general practice is often in small groups, and often of a one-to-one nature, facilitating good teaching experiences, and allowing students to watch a health professional in action and permitting discussion of the wider remit of primary medical care. We suggest that one such role could be that of teaching about professionalism.
WHAT IS PROFESSIONALISM?
Recently there have been several reviews of medical professionalism, but they each provide their own definitions of said professionalism. A team from the US defined professionalism as an ability to meet the relationship-centred expectations to practise medicine competently.10 This definition encompasses constructs such as respect for others, integrity, altruism, accountability, duty, composure and sensitivity to diversity.
In The Netherlands, a group of interested professionals suggested three themes of interpersonal, public, and intrapersonal professionalism, with 90 separate elements. The authors suggest this is a start to understanding professionalism, but conclude that it is context-dependent (in terms of which branch of medicine is being discussed), and also career-dependent (in terms of the levels of experience of the individual)11.
In the UK, Hilton concludes that there are three personal (intrinsic) attributes of professionals and three cooperative attributes.12 The former comprise ethical practice, reflection/self-awareness and responsibility/accountability for actions, whereas the latter comprise respect for patients, working with others and social responsibility. He concludes that a definition of a mature medical professional could be ‘a physician who is reflective and who acts ethically’.
These definitions are helpful, but there is no definition of professionalism upon which all agree, although there is some overlap. In addition the human face of professionalism appears to be relatively undervalued, and there is no link with a role within the local community. We will now try to see if the construct of the mensch helps us here.
The definition of mensch is variable, partly because it comes from a verbal tradition rather than a written one. A definition from the US is: ‘A person having admirable characteristics, such as fortitude and firmness of purpose, who radiates a kind of fundamental decency’.13 A further even shorter definition is: ‘A decent responsible person with admirable characteristics’.14 These attributes may be difficult to define, but culturally communities would pragmatically recognise a mensch, even if they might not agree on all the appropriate characteristics comprising such a person.
It is noteworthy that there is no completely and universally agreed definition of a mensch, just as there is no agreed definition of professionalism. We propose that attempting to define terms too rigorously risks missing the point of acknowledging and recognising the overlap of ethical and humanistic qualities that are central to the constructs of both. Further, as practical, pragmatic professionals working with our patients, every GP would surely be able to recognise the principles involved in both the mensch and professional values. There is now a challenge to every general practice-based medical educator to demonstrate the depth of professionalism in ‘everyday encounters’ to medical students.
HOW DO STUDENTS LEARN TO BE PROFESSIONALS?
Undergraduate medical students are expected to learn about professionalism, although how they do this is unclear; it has been noted before that previous generations were not overtly taught but rather learnt by ‘osmosis’.15 At this juncture, it is important to be aware of the two models of learning that are relevant here.16 The algorithmical model is akin to formal instruction, operating by reducing knowledge to a finite set of unambiguous instructions that can be passed to another person and followed exactly, and forms the basis of much of students’ clinical skills teaching.
The enculturational model differs in that it relates to the acquisition of skills through participation with expert practitioners. This model is dependent on a concept of ‘tacit knowledge’,17 where the nature of the skill remains unarticulated, but is learnt through observing and emulating experts. The acquisition of professional attitudes and skills by medical students depends largely on this model.15
However, in an era where medicine has had several ‘causes celebres’ (Harold Shipman, Bristol and Alder Hay for example), and as the subject of medical professionalism itself becomes more prominent, enculturational acquisition of professional values alone may be insufficient. The General Medical Council has indicated that the teaching of professionalism warrants more detailed attention.18 Many medical schools now hold ‘professional awareness days’, where more formalised discussion of professionalism takes place.
Some attributes of good medical practice, such as good communication skills,19 can be formally taught. Professionalism is also a necessary skill to acquire because it is one of the attributes of a good doctor, and ideally it is equally applicable for doctors to be professional in non-medical settings.18 Within a UK department of general practice, Howe emphasises that this topic deserves further recognition, resources and time within the curriculum, and notes a function for role models.20
The acquisition of professional values also needs informal settings to develop properly, and this requires an understanding of the ‘hidden curriculum’ in medical education.4 We suggest that students could be prompted to observe all doctors and other health professionals in action, but particularly GPs, to provide opportunities to reflect on professional behaviour that they might use themselves in future. In principle we agree with Hilton: ‘No matter how much we write about professionalism's importance … it is the day to day experience of working within a clinical environment that will be most fulfilling in its development’.12
This discussion places the mensch concept as a cornerstone in clinical learning. The mensch concept is not vital to a teacher's understanding of professional values per se, but the construct can be used to put a human face on a grey concept, and the term can be used as shorthand for our understanding of the application of professionalism and professional values.
APPRENTICESHIP
Students used to learn by being on wards and observing medicine, in a manner akin to an apprenticeship. Currently, students have fewer opportunities to observe individual medical practitioners in action in this way, especially with the increase in class sizes at UK medical schools. Further, there is less time to discuss how these practitioners deal with professional issues, relating to ‘triple diagnosis’ (biomedical, individual and contextual) issues around individual patients,6 or to ethical and moral dimensions.
This loss of the ‘informal curriculum’ may result in reduced learning and teaching opportunities with individual practitioners.4,17 Medical students and qualified doctors need to reflect upon professional values, and a pragmatic discussion of the virtue of the GPs that students encounter may be able to help students develop reflective ability. This will complement formal teaching in communication skills,19 and reflective portfolios,21 and add an extra dimension to professional learning.
Not all good GPs will make good teachers,5 even though teaching is a necessary professional attribute for doctors.18 It is difficult to define good doctors or good teachers, but we start from two basic premises — teaching should be undertaken by those with genuine interest and ability,5 and a good teacher is one who is interested and turns up on time.3 It is by being with a good doctor (acting as a mensch) that students can see equity, clinical wisdom and ethical values in action. These should be characteristics of good UK general practice, and students will benefit from watching and observing good practice extending beyond clinical skills and into the realms of good professional behaviour. The theoretical and practical aspects of discussing what constitutes an honourable doctor may be suitable as a starting point.
CONCLUSIONS
The purpose of this article is to focus on issues of professionalism, how the attributes of a good doctor are imparted and acquired, and how general practice can help in this regard. As teachers, we have found the concept of the mensch helpful in demonstrating professionalism to undergraduate medical students during their attachments in general practice. By definition, ‘menschness’ is unique to one culture, but we suggest that other cultures are likely to have equivalent concepts.
We advocate combining the dual benefits of contemporary educational principles with role modelling, and we propose reflection as a built-in element of medical education. We want students to consider elements of wisdom, heart and mind in the clinical encounters they have seen, and to reflect on how they might adopt these principles into their own professional careers. We would urge the readers of this article to look for the mensch in their own cultures and consider applying it to their teaching, and also to their everyday practice of medicine in the community.
- © British Journal of General Practice, 2006.
