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Teaching Professionalism

Bruce Gewertz, MD

By Bruce Gewertz, MD
Surgeon-in-Chief, Chair of the Department of Surgery

Pretty much every week, I receive a written compliment about the care and dedication of one of our house staff. These comments are originated by patients, families of patients and staff. On occasion, I hear from attending physicians or residents from other departments who want to be sure a good deed is recognized. Indeed, these positive and unsolicited tributes outnumber any complaints by a factor of more than 10.

Patients commonly write about the time and effort residents take explaining a complicated condition or being certain the patient's diet is advanced with the next meal — not waiting until tomorrow's breakfast. The actions range from the most important to less critical aspects of medical care and life.

In the current evaluation of residents, the teaching staff is required to evaluate a wide range of behaviors often grouped under the broad category of "professionalism." While we might all agree professionalism is important, one could ask when are these behaviors taught? It is true that we have few if any didactic sessions centered on the topic.

Still, any experienced physician can identify, often with great passion, how these attitudes and practices are developed.

The answer is role modeling. Residents learn from observing the exemplary behaviors of our large number of private physicians and faculty as they interact with patients and families in every inpatient and outpatient venue, on the telephone and, tellingly, even in conversation among themselves. This is the "hidden curriculum" of medical training, and it is our most powerful course.

The good examples are prominent in our memories. I can still remember the experienced endocrine surgeon at the University of Michigan who taught me that sitting down in a patient's room, even for one minute, sends a strong signal that you are there and engaged and willing to spend whatever time is needed. Paradoxically, once so assured, patients pose few extraneous questions or comments, rarely prolonging the visit beyond what is needed.

The actions of an esteemed gastroenterologist I met in medical school illustrated two key factors in gaining patient trust — maximizing eye contact and the laying on of hands. He often remarked that he tried to be doing one of those two activities the entire time he was with a patient. I can't imagine how he would react to our modern necessity for electronic medical recording of information, which too often offers patients a turned back during minutes of furious documentation.

We all likely have favorite stories of equanimity and compassion. My surgical idol in medical school allowed me to spend a month with him in the O.R. and his office. Once, a patient, cured of lung cancer by a pneumonectomy, bitterly complained, "How could you send me such a large bill? Have you no compassion?" Instead of responding with hostility to the questioning of his character — after all, the patient had sailed through a big operation and it was successful — the surgeon offered to reduce the bill to what the patient thought was reasonable and consistent with his resources.

The surgeon's composure and willingness to waive part of his fee (even in the face of an aggressive inquiry) taught me more than watching the elegant operation.

In sum, senior physicians and senior residents alike have a great responsibility to pass on these lessons. Our students will profit from us pointing out our successes and, even, our occasional shortcomings in these areas.

Based on my experience here, the good news is that the lessons are getting through.