UND photo by Chuck Kimmerle

Professionalism:
The Responsibility of the White Coat

“You can pass all your exams with flying colors, but if you do not act in a respectful and professional manner, I am going to kick you out of here,” says Dean H. David Wilson, M.D., in his annual speech to new medical students who arrive each August at the University of North Dakota (UND).  

At the UND School of Medicine and Health Sciences, professionalism is at the core of the curriculum that educates tomorrow’s doctors. 

“Doctors in the 21st century face new challenges,” said Charles Christianson, M.D., associate professor of family medicine and head of the Strategies for Teaching and Evaluating Professionalism (STEP) project at the UND medical school.  “They are no longer the unquestioned, all-knowing physician.  Patients research their problems on the Internet and expect their doctor to educate and communicate with them; society expects more accountability, and insurance companies exert more financial pressure.  There are troubling issues of the proper relationship of physicians to the drug industry.  Our students need to leave medical school knowing how to deal with those pressures appropriately.”

A recent University of California study, which looked at medical school records of doctors who had been disciplined by their licensing boards, reveals that even in medical school those doctors showed unprofessional behaviors such as failing to carry out their responsibilities, only doing enough to get by, not taking feedback well and developing bad relationships with fellow students and co-workers. 

In 2003, UND was selected as one of ten medical schools to receive funding from the American Medical Association (AMA) to develop its STEP project, to look at how professionalism can best be taught in medical school and beyond.

“With the STEP project we strengthened our professionalism teaching in the preclinical years,” said Christianson, who came to UND after 25 years in the Washington, D.C., area, where he was in private practice for 10 years and taught at Georgetown University School of Medicine, finishing his service there as vice chair for academic affairs in the family medicine department.  “The patient-centered learning curriculum here lends itself to professionalism development early in medical school.” 

Through the unique, patient-centered learning curriculum at the UND medical school, students have contact with patients starting the very first week of classes.  Three afternoons each week are devoted to the clinical sciences, including the patient-physician relationship, ethics, behavioral and professional issues and other issues that arise from the case of the week. 

“In the first two years our contact with standardized patients taught us how to approach and examine real patients with respect and sensitivity,” said Andy Bakke, a fourth-year medical student. 

“Case-based learning offers the opportunity to present professionalism, ethical and behavioral sciences issues in the larger context of patient care,” said Christianson.  “For example, one case deals with breast cancer.  Although the students learn the pathology of cancer, they also examine the elements of informed consent and how the process should be carried out.”

The ‘Hidden Curriculum’

Incorporating and emphasizing professionalism into the formal curriculum ensures that students are exposed to these important issues from a very early stage of their education.  However, students learn more than what the curriculum offers during their medical school education and it is this implicit learning or “hidden curriculum” that Christianson and his team have also been studying. 

This past summer, the UND School of Medicine and Health Sciences was one of only eight medical schools in the country to be invited to attend a special conference aimed at examining how the culture of a medical school shapes medical students’ values, attitudes and behaviors.

Through a competitive process, the following medical schools were selected to send representatives to the Relationship-Centered Care Initiative Immersion Conference, hosted by Indiana University School of Medicine at Indianapolis: Baylor College of Medicine, Dartmouth Medical School, Drexel University, McMaster University, Southern Illinois University, the University of Missouri-Columbia, UND and the University of Washington.

“Those of us in medical education spend a lot of time planning the facts, clinical skills and principles of medicine that we teach to our students,” said Christianson. “But one of the most important and lasting aspects of the students’ experience is the informal education, sometimes called the ‘hidden curriculum,’ that occurs as students are exposed for the first time to the culture of the clinic and the hospital ward.”

Dean Wilson congratulates Andy Bakke, Grand Forks, now a fourth-year medical student, during the White Coat Ceremony in 2002.

Rosanne McBride, Ph.D., a psychologist and assistant professor of family medicine, has extensive experience teaching behavioral issues to physicians and says the key to really dealing with the “hidden curriculum” of a medical school is a process of self-reflection, as individual students and faculty and as an institution. 

UND’s unique patient-centered, case-based curriculum in the first two years of medical school helps to develop the practice of reflection.  At the end of each week, each learning group reviews its performance during that week and draws lessons for the future.  On a regular basis each student performs an individual self-assessment including his or her strengths and plans for improvement, then meets with the facilitator, who has performed the same assessment on the student.  The two discuss and reach a common understanding of the student’s strengths and plans for improvement. 

“This begins a process of life-long self-evaluation and active learning,” said McBride who recently received a Bush Teaching Scholars Fellowship to look further into this issue.  “This process in the first two years of medical school initiates models and reinforces the importance of a life-long process of reflection and self-assessment leading to professional development.”          

As a way to encourage reflection in the third year of medical school, which is the first year of clerkships, Christianson originated a pilot professional development group for students on the Grand Forks campus. 

Those six students meet monthly with a faculty facilitator to discuss ethics and professionalism issues.  The students rotate responsibility for choosing a topic and leading the discussion on topics such as end-of-life and code status issues, how to respond when an attending makes an insensitive remark and the relationship of students to drug company representatives. 

“The group gave me a great opportunity to reflect on my own professionalism,” said Nicole Veitenheimer, fourth-year medical student, who participated in the pilot professional development group.  “It gave me a chance to hear about my peers’ experiences in their clerkships and to think about what I would do if I was in the same situation.”

“The third-year focus group brought to light many issues we as students encountered on the wards and allowed us a venue to exchange our thoughts and feelings about them,” agreed Bakke, who was also in the group.  “We could then consider how we would handle these situations before actually experiencing them.”                      

Is it making a difference? 

Christianson and his colleagues recently received another grant from the AMA to examine if the work being done to instill professionalism in medical students is truly working.  The team plans to look at the range of medical practice from medical school through residency training and especially at the challenges faced by practicing physicians.

To do this, they have developed a unique collaboration with the North Dakota Medical Association (NDMA) to help support professionalism among physicians in the state and to involve them in teaching professionalism to students and residents. 

Robert Beattie, M.D., the new chair of family medicine, helped to develop the project.  Recently completing two terms as president of NDMA, he focused on professionalism as a major theme of his presidency. 

Christianson, Beattie and McBride attended a national meeting in February with the 16 grantee-organizations to brainstorm approaches to enhancing professionalism across the spectrum of medical practice.

return to top