The unprincipled student as good doctor: The medical education scholarship of professionalism

Abstract

The CanMEDS framework underpins much medical education in Canada by inculcating students and Residents with the roles and attributes of what has been deemed to be a “good” doctor; CanMEDS roles also are designed to direct the quotidian behaviour of fully fledged physicians. Supplementing, or often infused within these roles, are the tenets of the “good” doctor as espoused by healthcare ethicists which are grounded in the “Georgetown mantra” with its four apparently self-evident “principles” of patient autonomy, social justice, beneficence, and non-maleficence as promulgated in the canonical (and best-selling) text book Principles of Biomedical Ethics by Beauchamp and Childress. But clinical, or medical, or healthcare ethics—bioethics in general—as understood today, even in its current international practice, is both a recent and an American invention. Noted philosopher and physician H. Tristram Engelhardt, Jr. reminds us that around 1968-9 the field was “made in America and then exported across the world, something like Coca Cola and McDonald’s.” More recently, the “principles” approach to training “good” doctors has come under increasing scrutiny by physicians, philosophers, some ethicists, and others critical of the drawbacks and limitations of short-cut applications of thinking only in terms of patient autonomy, social justice, beneficence, and non-maleficence as a template formulated within a specific cultural place and time (America of the turbulent 1960s). My paper therefore explores the medical education consequences of the following question: Might an “unprincipled” student still become a “good,” if not a better and more professional doctor? Reviewing current literature, I shall offer an intellectual critique of the principlist “Georgetown mantra.” Following, I shall describe an alternative and/or supplementary framework for educating medical students based on a distillation of the burgeoning scholarship on professionalism (including “physicianship”); as I will show, a literature search demonstrates the phenomenal growth of this topic. Also exemplary, is the ongoing special series of essays in CMAJ devoted to professionalism (see http://www.cmaj.ca/site/earlyreleases/24may12_professionalism_the_good_doctor_discussion.xhtml). I conclude by inviting forum participants to reflect on the various educational frameworks designed to address the “good” doctor, but noting that the bioethics template although explicitly grounded in patient advocacy is intrinsically antagonistic toward the practice of medicine, while the professionalism/physicianship model has been crafted primarily by the medical community itself to address the concerns of both society and practitioners for their mutual benefit.