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The Role of Character in Medical Education. Prof. James Arthur. Statement on Character, Virtue and Practical Wisdom in Professional Practice (2016).
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The Role of Character in Medical Education Prof. James Arthur
Statement on Character, Virtue and Practical Wisdom in Professional Practice (2016) ‘The professions enjoy a unique and privileged place in the public eye. They are relied upon for moral probity, diligence, fairness and resolve, frequently in complicated circumstances and often in the face of conflicting demands. Professional people are expected to do the right thing; and they are expected to do the right thing both for individuals – be they clients, customers, patients, pupils, victims of crime or enemy combatants – and for society at large.’ (Jubilee Centre for Character and Virtues, 2016)
Virtuous Medical Practice: Research Report (2015) Over 2 years, this research project investigated the place of character and virtues in the training and professional practice of medical doctors in the UK.
Virtuous Medical Practice - purpose and overview • The project examined how understanding virtue concepts influenced moral thinking & conduct amongst doctors. • Findings were drawn from a sample of 549 practicing and trainee doctors, at 3 different career stages (first year and final year students and their educators, as well as experienced practitioners). • Using virtue-based methods – ethical dilemmas in particular – it aimed to provide the profession with a baseline to design future educational interventions.
Virtuous Medical Practice - research questions Which virtues and values are held by members of the medical profession in the UK? How do doctors develop these virtues and values? How do virtues and values shape medical practice? How do these virtues and values relate to the expectations of the medical regulatory bodies? What are the implications of virtue-based medical ethics for ethics education? How can virtues and values be developed through doctors’ initial training and continuing education?
Virtuous Medical Practice - background • British Context • Political devolution; • Greater scrutiny in era of public sector cuts and emphasis on accountability; • Curricular reforms; • Health care structure; • Examples of scandals in healthcare system (mid-Staffs): ‘lack of care, compassion, humanity and leadership’, Robert Francis QC.
Virtuous Medical Practice - background • Character and Ethical Practice in Medicine • Virtue ethics vs. rule-based practices and regulations; • Tallis’s (2006) 3 reasons why medicine needs to examine itself: • technological advances – info available to patients; • decline in deference – patients challenging expertise; • intensified consumerism – higher patient expectations.
Virtuous Medical Practice - measuring character • Although difficult, virtue-based approaches must develop valid, reliable measures to challenge the dominance of rule & code. • However, no agreed method to understand the moral character of professionals currently exists. • VMP chose to ‘investigate the prospects for developing virtue-based studies of moral development in medicine’ (2015: 11): • This approach sought to encompass more than just moral reasoning; • And it is profession-specific, placing more emphasis on context. • Moral dilemmas were employed for this measure.
Virtuous Medical Practice - methodology • Mixed-methods, cross-sectional study allowing for comparison of 3 career stages: first year students; final year students; professional doctors with 5+ years experience. • Literature review and expert panel consulted at outset. • Two principal instruments of data collection were designed as a result: the survey (including dilemma scenarios); semi-structured interviews. • Data gathered from participants at 4 sites across the UK to ensure good geographical representation.
Virtuous Medical Practice - survey • The survey consisted of 5 sections (4 for first year students): • Self-reports on character strengths (respondents chose top 6 strengths from VIA survey); • Reponses to professional dilemma scenarios (6 tests designed by expert panel; response & reasoning given); • Views on the ‘ideal’ professional (respondents gave top 6 strengths which they thought described ‘ideal’ doctor); • Views on work or study environment (adapted from Europe-wide workplace survey); • Demographic questions.
Virtuous Medical Practice - semi-structured interviews • A themed set of questions were devised based on research questions. They examined: • reason for entering the profession; • characteristics of a good professional; • factors that help or hinder being a good professional; • influence of character on everyday practice; • influence of professions code on conduct; • influence of education & training in developing strengths necessary for good professional practice.
Virtuous Medical Practice - numbers of respondents Total Respondents: 549 Students: 274 Professionals: 275
Virtuous Medical Practice - findings RQ 1 • What do we know about the character of medical students and doctors from what they say about themselves? • Five strengths from the 24 (VIA-survey) were selected by participants across all cohorts as best reflecting their personal character: fairness; honesty; kindness; perseverance; teamwork. • One difference emerged, with final year students also reporting humour (in their top 6), and first years reporting curiosity. • In interviews, experienced doctors felt they learnt more about conduct and professional character through workplace experience, whilst their education had given them the necessary knowledge and competence.
Virtuous Medical Practice - findings RQ 2 • What do we know about the character of the good doctor from what medical students and doctors say about good doctors? • All three cohorts placed the same 6 strengths as most important when considering the ‘ideal’ doctor: fairness; honesty; judgement; kindness; leadership; teamwork. • This level of agreement in the profession was significant and notably higher than the same analysis for lawyers and teachers (see other JC research – Arthur et al. 2014; Arthur et al. 2015). • The results also highlighted overlaps between personal strengths identified by the sample and ideal strengths. However, respondents were more likely to report leadership and judgement as ideal strengths than they were to identify them in themselves.
Virtuous Medical Practice - implications • How is character learned in medical education? • Virtuous Medical Practice highlights, whilst there is a long way to go, UK medical schools understand the importance of ethics education. • The findings suggest that integrating ethics throughout the curriculum is a priority – especially given the power of the ‘hidden curriculum’. • The importance placed on clinical placements by med students for learning best ethical practice, as well as the interview evidence showing changing attitudes to the General Medical Council guidance, show how ethics is learnt implicitly through practice & example. • Medical students also reported good role models as being an important factor in developing positive character strengths.
Virtuous Medical Practice - implications • Content of the medical ethics curriculum • Whilst guidance from the UK’s Institute for Medical Ethics suggests that ethics education should create ‘virtuous doctors’, studies of the ethics curriculum often take deontological or consequentialist approaches. • Although there is an awareness in the curriculum that knowledge of medical ethics and law isn’t enough, little provision for this is included. • Likewise, the General Medical Council’s practical guide Tommorrow’s Doctors implicitly identifies a difference between virtue knowledge and ethical practice. • It seems this disparity is principally due to acknowledged problems with accurately measuring virtue & professionalism.
Virtuous Medical Practice - implications • Relevance of virtues and values in medical training • In light of the above, the study aimed to inform the development of medical ethics curricula as follows: • Emphasis on the virtues of fairness, honesty, judgement, kindness, teamwork and leadership (‘ideal’ medic) can help focus character education in medical ethics. Further study of these virtues in medical contexts should be undertaken. • The self-report results of students’ and doctors’ strengths can provide a baseline for future comparative study. • Using situational judgement tests, the study highlighted for the first time how moral dilemma tests can be used to understand and assess virtue in practice.
Virtue, Practical Wisdom and Professional Education (2017) (Pilot Intervention – Medicine) • This project developed, implemented, and piloted a new course, entitled Character in the Professions, designed to introduce the concepts of character, virtue, and practical wisdom (or professional phronesis) to student lawyers, teachers and doctors. • In total, 1,456 students from eleven institutions across Britain participated in the pilot course. None of these eleven institutions had previously taught a discrete course on character-based professional ethics, as opposed to rule and code focused ethics.
Virtue, Practical Wisdom and Professional Education (Medicine) • ‘Interventions’ – Course Structure (3 Units) • Introduction to character and virtue ethics: • What is virtue ethics? • What is phronesis? • How does phronesis apply to the professions? • Why does character matter? • Character in the Medical Profession. • Reflection: • Quiz and survey giving feedback on the course; • Reflective essay and presentation; • Ethical dilemma app – compare answers and discuss.
Virtue, Practical Wisdom and Professional Education (Medicine) Unit 2 – Character in the Medical Profession 2. a) Phronesis in Medicine; 2. b) Doctors in the News; 2. c) Personal Character Virtues; 2. d) Role Models; 2. e) Ethical Dilemmas 2. f) Good Medical Practice
Virtue, Practical Wisdom and Professional Education (Medicine) • Example Activities: • 2.1. Phronesis in Medicine: • Students receive an overview of how virtue ethics in medicine differs from deontology and consequentialist theories. • They are then asked to complete the VIA survey & apply apt character strengths for the profession. • These are then discussed in relation to an infamous case.
Virtue, Practical Wisdom and Professional Education (Medicine) • Example Activities: • 2.5. Ethical Dilemmas: • Students are given a number of walkthrough and example videos on negotiating moral dilemmas. • They are then asked to consider 5 different moral dilemmas (the same as those considered in VPM). • They then have to present answers to the 6 questions parallel.
Virtue, Practical Wisdom and Professional Education (Medicine) • Course Evaluation • Mixed methods: data collected through interviews, surveys, and written examples of work by students who participated in the course. • Trainee professionals from all cohorts found the ethical dilemma activity to be the most useful and enjoyable; • 86% of medical students judged the course relevant to their education; • Of the three professions studied, UK medical students had least knowledge of virtue ethics & phronesis prior to the course; • Medical educators were slightly concerned about a clash between phronesis and ‘professional judgement’ – something already taught in medical education.
Other work in this area… • Despite the lack of awareness of phronesis amongst some medical students, more research is emerging on this topic amongst medical educators. • The University of Dundee Massive Online Open Course (MOOC) in ‘Compassionate Care: Getting it Right’. This course aims to increase compassionate care for service users and professionals. The five-week course focuses on examples of effective compassionate care, as well as recent concerns over a perceived compassion deficit in healthcare. • ‘Phronesis and the Medical Community’ – University of Birmingham. • Teaching ‘Wisdom’ to Medical Students’ – University of Virginia.
Phronesis and the Medical Community (TBA, 2018) (HMSC, University of Birmingham) ‘In our study, “Phronesis and the Medical Community”…we will conduct interviews and observations and use diary methods to collect narratives of wise decision-making from 120 participating medical students and doctors. Participants will be taken from three medical schools and their associated hospitals in the West and East Midlands. These narratives will present data to help us illustrate what phronesis means in current medical practice, the extent to which it is possessed by practitioners and seen to be possessed at various stages of their career, and how it develops over time’ (Kotzee et al, 2016: 348).
Teaching ‘Wisdom’ to Medical Students: The Phronesis Project University of Virginia One initiative that stands out is the ‘Phronesis project’ at the University of Virginia, USA founded by Dr. Margaret Plews-Ogan. The project is trialling a new phronesis curriculum, building early and long-term relationships with patients, and encouraging students to ‘see the patient as a person, rather than their disease’. ‘Our educational goal is to foster our capacity for wisdom development, setting the stage for wisdom development throughout our careers’.
Medical College of Wisconsin? • Potential Research Questions • Do doctors have to have character traits to be "good" doctors? • How much character can one develop once they begin their medical training (typically age 22 or older)? • How do we identify character in applicants to medical school? , what tools are available?
Conclusions Each person is a someone, not a something. Other people matter. We need to judge decisions as good, or not, in the context of the best values, expectations and needs of those with whom we should seek to build relationships (patients). Therefore we should not make decisions in a self-interested, self-determined, closed world that does not weigh sufficiently the impact on others. Start with basic honesty and integrity so that each and all receive what they are entitled to or can reasonably expect. This is the first stage of building trust. Then go beyond this minimum, using knowledge and capabilities to provide benefits that people desire and value but cannot expect or demand.
Conclusions Be clear about who you are and what you stand for, combining this with an openness to enrichment from others. Favour curiosity and inclusion over suspicion and exclusion. Show respect for the dignity of each person and for the whole person; never use people as a means to achieving business objectives. Demonstrating respect means setting a purpose and seeking outcomes that enable each person to reach his or her full potential. Genuinely aim to promote the good of society by building the character virtues of all.
