Healing the system by restoring its most important virtues
Healing the system by restoring its most important virtues
Henk ten Have 0 1
Bert Gordijn 0 1
0 Pittsburgh , PA , USA
1 & Henk ten Have
Asking health professionals if there are any heroes in their area of work will most likely result in diverging replies. In France they will probably mention Louis Pasteur for his discovery of micro-organisms and vaccination; in GreatBritain Joseph Lister for making surgery safe with his antiseptics. Others will refer to colleagues who changed practices; for example, Florence Nightingale or Albert Schweitzer. Identifying heroes is more common in the US than other countries. CNN is listing every year the top ten heroes, also in healthcare (CNN 2015). The Center for Information and Study on Clinical Research Participation in Boston is running a Medical Heroes Campaign (CISCRP 2016). Volunteers participating in clinical trials are the everyday heroes who help to promote medical science. Then there are the unsung heroes who work day and night without being recognized.
Osler
For many physicians one of the uncontestable heroes of
clinical medicine is William Osler, who created the first
residency program at the new Johns Hopkins University in
1889. His model of bedside clinical training has become
the dominant approach of graduate medical education
across the world. During these clinical years not only
knowledge and skills are acquired but also professional
values and attitudes. This is the period shaping the values,
attitudes and behaviors of young physicians. In the
residency system the emphasis is on learning by doing,
implementing the philosophy of John Dewey and
practicing habits of thought. It is an environment where learning
is a communal activity with grand rounds, morning reports,
and interactive discussions. It articulates critical
intellectual qualities; students should not just know what to do but,
more importantly, understand why it should be done. It also
articulates the moral dimension of healthcare; the patient
comes first; care is a duty; health professionals need to be
attentive, thorough, and empathic.
Virtues
Osler is the icon for an educational environment for
generations of health professionals. He is a medical hero
because he bridged in practice a gap that is often assumed
in theory: the divide between science and ethics. Osler
demonstrated that scientists need virtues, that specialist
expertise requires moral responsibility. His view of
medical education that became popular everywhere also
indicated that virtue ethics is the oldest and most advocated
approach in medical ethics. The moral character of health
practitioners is vital for good patient care, not merely their
technical and rational capabilities.
In this issue of the journal the significance of virtues is
emphasized by
Kotzee and Ignatowicz (2016)
. They
discuss the importance of moral character but point out that
virtues are difficult to measure. Assessment of ethics, for
example in ethics education, is usually focused on
measuring moral reasoning. But health professionals often need
to be able to interpret experiences and meanings of critical
illness and suffering. This requires self-reflection and
humility since this reminds them of their own vulnerability,
but it also demands virtues such as empathy and
attentiveness.
Changed context of education
Although virtues play a crucial role in healthcare, the focus
on virtues does not take into account a major problem in
present-day healthcare: the context of medical education is
changing. In his recent book Let me heal, Kenneth
Ludmerer, physician and historian of medicine, shows how
residency education is eroding and disappearing
(Ludmerer
2015)
. The overall quality of the educational environment
is declining. Hospitals have developed into large medical
centers delivering ever growing numbers of patient
services. Stays in hospital are shortening; more and more
patients are admitted. Burnout among residents has
increased; the context of care has become impersonal;
young physicians have less supervision; they need to focus
on productivity and throughput, providing more and more
service duties as a cheap labor force for the hospitals. In
this context of patient care as a market commodity, speed
and efficiency are paramount. The overriding goal is to
discharge patients as quickly as possible. There is no time
for reflection, for relationships with inspiring teachers, or
for attention to patients.
Learning environment
Ludmerer concludes that ‘‘…the education of tomorrow’s
doctors is endangered by our country’s commercialized
system of health…’’
(Ludmerer 2015, page xii)
. This
deterioration of the learning environment makes it
increasingly difficult to articulate, practice, and reinforce
virtues that are necessary for good patient care. Hospitals
as service agencies precisely articulate the virtues of
commercial business with physicians and nurses as patient
managers and efficient providers. Unfortunately, the
dominance of business virt (...truncated)