Medical Professionalism and the Formation of Residents: A Journey Toward Authenticity
David C. Leach, Medical Professionalism and the Formation of Residents: A Journey Toward Authenticity
Medical Professionalism and the Formation of Residents: A Journey Toward Authenticity
David C. Leach M.D.
PROFESSIONALISM AND THE
OF RESIDENTS: A JOURNEY
DAVID C. LEACH, M.D.*
Let me begin by thanking the Holloran Center and the Law Journal of
the University of St. Thomas School of Law for the opportunity to share my
thoughts and observations about medical professionalism—in particular,
medical professionalism as it pertains to the formation of resident
physicians. Medicine, unlike most professions, requires a period of formal,
supervised training after graduation. These educational programs, called
residencies, are accredited by my organization, the Accreditation Council
for Graduate Medical Education (ACGME).1 There are 8,186 residency
programs in the country, which in the aggregate house 103,367 residents in
122 specialties and subspecialties.2 I will use residents and residencies to
illustrate both the problems and opportunities associated with our topic: the
formation of an ethical professional identity. The questions of
professionalism and the formation of young professionals can thus be stated: How do
we preserve and nurture authentic human and moral reflexes in our young
learners? How do we foster authentic professionalism and moral
development in young people when the context in which young people are being
formed is itself morally challenged?
This article is organized into three sections: first, background
information about residents and residencies; second, examples, both egregious and
normal, of challenges to resident formation; and, finally, proposed solutions
to address these challenges.
* Former Executive Director and CEO of the Accreditation Council for Graduate Medical
1. Accreditation Council for Graduate Medical Education, http://www.acgme.org (last
visited May 7, 2008).
2. 2005–2006 Annual Report, 2006 ACCRED. COUNC. GRAD. MED. EDU. 8–9, available at
As any of the nation’s 106,000 medical residents could attest,
residency is an intense experience with a learning curve steeper than any other
area of physician formation. The differences in knowledge and skill
between first-year and chief residents are profound. The residents’ journey is
one in which they learn the practical skills of medicine. Residents discover
clinical wisdom, yet they also discover themselves. They are seeking to
become authentic physicians. It is a journey that is surrounded by external
drama, but actually proceeds from the inside. It is a journey that calls not
only on their intellect, but also on their will and their imagination.
Residents learn to discern, tell the truth and make good clinical judgments in
very complex, clinical situations.
Because of the intensity and importance of this most formative phase
in physician development, and because the habits of a lifetime are
developed during this period, we (the staff and volunteers of the ACGME) pay
attention not only to the residents’ progress, but also to the context in which
residency occurs. The learning environment is crucial and is monitored by
ACGME’s Institutional Review Committee.3 Residents and residency
programs offer a particular view of the formation of an ethical professional
SOME CHALLENGES TO THE FORMATION OF YOUNG PROFESSIONALS
One of my mentors, Parker Palmer, a sociologist in Madison,
Wisconsin has said:
Hope is not the same as optimism. An optimist ignores the
facts in order to come to a comforting conclusion, but a hopeful
person faces the facts without blinking—and then looks behind
them for potentials that have yet to emerge—knowing that the
human experiment would never have advanced were it not for the
possibilities, however slim, that lie hidden behind the facts.4
Using Palmer’s definition I can say that I am cautiously hopeful, but
definitely concerned, about the formation of medical professionals in the
In May 2002, Palmer facilitated a retreat for residency program
directors who had received the ACGME’s Parker Palmer Courage to Teach
Award. During the retreat, a case was presented about a liver transplant
donor who had died while in intensive care. He died despite the fact that the
surgery had gone smoothly and despite the fact that his wife, who was with
3. For a description of ACGME Institutional Requirements, see ACGME Institutional
Requirements, 2007 ACCRED. COUNC. GRAD. MED. EDU. 1–17, available at http://www.acgme.org/
4. Parker Palmer, Address at the Marvin Dunn Memorial Lecture at the ACGME
Educational Conference: The New Professional—Educating for Transformation (Mar. 4, 2006).
him throughout the entire post-surgical period, insisted repeatedly and to no
avail that her husband was going downhill fast. Three months later, the
State Health Commissioner issued an incident report saying: “The hospital
allowed this patient to undergo a major, high-risk procedure and then left
his postoperative care in the hands of an overburdened, mostly junior staff,
without appropriate supervision.”5 On the day the donor died, a first-year
surgical resident with twelve days of experience in the transplant unit had
been left alone to care for thirty-four patients. She could not—and did
not—monitor every patient with the care and precision required.
I present this case as an example, perhaps an extreme example, of
abandonment not only of the patient, but also of a very junior resident. I
also present it because of the response it evoked from a set of doctors
analyzing it. The doctors at the “Courage to Teach” retreat discussed the case
in small groups and almost universally came to the conclusion that system
issues were to blame. The analysis was impersonal and abstract. Culpable
parties were the hospital leadership, the clinical department chair and the
system of supervision, inexperience and staffing.
During the debriefing, Palmer asked a question that brought the group
into deep silence: “Who is the moral agent of this story?” We were not used
to thinking in terms of moral agency. The group agonized over the question
and the fact that, by habit, we had avoided asking the question. Palmer then
inquired: “What if residents were expected to be the moral agents of the
institutions in which they work and learn?” He suggested that young
learners, not yet acculturated by prevailing institutional mores, offered a more
pure look at the moral issues in healthcare than those of us who, by
experience and habit, had developed a ready list of explanations to cope with such
This case invites exploration of several themes about the development
of professionalism and value systems in modern healthcare systems.
Although it is tempting to highlight the several external forces that influence
the developing professional today, I speak more to the developing
professional’s internal influences. To frame this discussion, I think of medical
professionalism as more potato than lettuce; lettuce rots from the outside in
while a potato rots from the inside out. For example, there has been much
talk about the influence of commercial support of education—I put that into
the lettuce category. It should not happen. Fixing it might involve removing
some of the outer leaves of lettuce that appear brown and slimy. For me,
and for many who take residency education seriously, the question of
professionalism is deeper and emerges from the internal: How do we preserve
and nurture authentic, human and moral reflexes in our young learners?
How do we foster authentic professionalism and moral development in
young people when the context in which young people are being formed is
itself challenged morally?
A Few Words about Language
ACGME has identified professionalism as one of six general
competencies used in the accreditation of residency programs. ACGME
requirements for professionalism include:
Residents must demonstrate a commitment to carrying out
professional responsibilities and an adherence to ethical
principles. Residents are expected to demonstrate:
Compassion, integrity and respect for others; responsiveness
to patient needs that supersedes self-interest; respect for patient
privacy and autonomy; accountability to patients, society and the
profession; and, a commitment to excellence and ongoing
. . . Sensitivity and responsiveness to a diverse patient
population, including but not limited to diversity in gender, age,
culture, race, religion, disabilities, and sexual orientation.6
As this definition makes clear, medical professionalism depends
heavily on the quality of a physician’s inner life. Transcendence of self-interest
is not a technique—it is a way of being. The resident, in addition to learning
the science and art of medicine, must also learn a new way of being in the
world in order to become a fully-developed professional. The resident’s
journey is an inner journey. We have a heavy obligation to help them.
Some External Variables that Influence Developing Professionals
Although the journey is deeply personal and the inner journey is
heavily influenced by context, both institutional and societal contexts influence
the development of professionalism. Is it possible to model and teach
professionalism in institutions that do not demonstrate professional values? Is
it possible to teach and model professionalism in a society that does not
demonstrate social justice, that accepts limited access to health care for the
uninsured, and that tolerates demonstrably worse healthcare outcomes for
No, the current context in which resident formation occurs does not
make the task of fostering medical professionalism easy. Relentless
pressures of time and economics, fragmentation of care and the relationships
6. ACGME Board, Common Program Requirements: General Competencies, 2007
ACCRED. COUNC. GRAD. MED. EDU., available at http://www.acgme.org/outcome/comp/General
CompetenciesStandards21307.pdf [hereinafter Common Program Requirements: General
supporting care, increasing external regulation, exciting but disruptive new
knowledge and technologies and, above all, the broken systems of health
care dominate conversations and characterize the external environmental
The Internal Context of Healthcare
In addition to external pressures, healthcare delivery systems
demonstrate their own internal values by their behavior. The news in this field is
not promising. The internal context of the system of care is daunting. We lie
regularly. Justifiable lack of trust pervades the system. Beth McGlynn7
estimates that only fifty-four percent of patients receive care that is known to
be the best, a number that falls to two or three percent when evidence-based
guidelines are bundled.8 Hospital websites proudly announce that the
hospitals they promote provide the best care with the best doctors, the best
technology, etc. Some are so detached from acknowledging human suffering
that they make it seem as though a hospital might be a fun place to visit. As
a profession we have tolerated that message, forgetting Hannah Arendt’s
adage that every time we make a promise we should plan for the
forgiveness we will need when that promise is broken.9
The hospital bill offers another example of a breach in
professionalism. It is frequently not interpretable, even by the hospital’s own
administrative staff—let alone patients and their families. Paul O’Neill10 has said
that he knows of no other industry that regularly accepts a thirty-eight
percent reimbursement on amounts billed, a percentage he states is the national
average. We all know how the number is derived. Hospitals actively
negotiate with several insurers in ways designed to cover costs. Inflated bills and
discounted deals result. This system, while cumbersome, works fine from
the hospital’s perspective, as long as the aggregate reimbursements cover
expenses and some margin. The system works fine, that is, until a patient
shows up with no insurance and with no one to negotiate for a discounted
rate. Further, the undiscounted fees are billed to those least able to pay. The
hospital bill is about as far away from “ compassion, integrity and respect
for others; responsiveness to patient needs that supersedes self-interest; . . .
accountability to patients” as one can get.11
It is hard to foster professionalism when incongruities between
espoused and evident behaviors are so apparent. I call this the “Abraham
Verghesse problem.” At a spectacular forum sponsored by the American
Board of Internal Medicine in the summer of 2005, the audience was, with
some justifiable pride, celebrating the accomplishments of the Physician
Charter on Medical Professionalism.12 This well-written document,
endorsed by many, clarifies principles and commitments in a very important
way. Yet, in the midst of the celebratory speeches, Abraham Verghesse
stood up and said that his medical students shrugged that the principles
espoused in the Charter were self-evident—it was why they went into
medicine. Why were so many making a fuss about it? Dr. Verghesse then
said: “Perhaps we pay so much attention to the words because there is no
other evidence that the phenomenon exists.” Everyone became silent.
In spite of these examples, I remain cautiously hopeful, using Parker
Palmer’s definition, because there are also a number of vectors in play that
serve to support the good moral development of young
professionals—vectors that can offer some hope for solutions.
There is a deep hunger for a return to classic professional values.
Many good people are seeking clarity about how best to do that in the
modern world. As Parker stated, “[in] looking for potentials that have yet to
emerge . . . [and] at the possibilities hidden behind the facts . . . ,”13 we can
find allies that can help move this particular human enterprise forward.
Dee Hock has said, “[s]ubstance is enduring; form is ephemeral.
Preserve substance; modify form; know the difference.”14 The task before us is
to be faithful stewards of the moral foundations of medical professionalism
while adapting to the new and emerging forms of medical practice. By
aligning the solutions to professional development with the fundamental
faculties of human nature, we are connecting with values in medicine—
truth-telling, altruism and practical wisdom— that go back several
millennia and give us a solid foundation on which to stand. If in fact medical
professionalism is like a potato, and not just lettuce, our responses to the
new forms of medical practice will either reveal deeper lesions of
professional values or opportunities to drag the goodness of medicine into the
How can we best proceed? I think it is best to work with, rather than
against, human nature. What does that mean? Residents, their teachers, and
all humans come equipped with three faculties that are naturally aligned
with the goals of professionalism: intellect, will and imagination.15 The
object of the intellect is truth, that of the will goodness, and that of the
imagination beauty. The job of a good doctor boils down to discerning and telling
the truth, putting what is good for the patient before what is good for the
doctor, and making clinical judgments that harmonize—harmonize in ways
that are creative and sometime even beautiful—the particular needs of a
patient with the general scientific evidence at hand. This construct invites a
new frame (or rather a very old frame) for organizing experiences: How
good a job did I do in discerning and telling the truth, in putting the
patient’s interest first, and in accommodating the particular realities of the
patient’s situation in my clinical judgments?
Some Examples of Truth-Telling in Healthcare
Some hospital websites are beginning to tell the truth about their
clinical outcomes. The Dartmouth-Hitchcock website, for example,
provides a list of several clinical procedures and diseases as well as
Dartmouth’s performance for each.16 Three columns then compare
Dartmouth’s performance with the national average and national best
performance. While still unavailable for most hospitals, Dartmouth is not alone
in its transparency; others are beginning to follow. The Cystic Fibrosis
Foundation website, for example, provides comparative outcome data for
each of the major cystic fibrosis treatment centers in the country.17 While
not yet available for other diseases, the data inevitably will be compared.
As a profession, we are beginning to tell the truth.
We are also beginning to tell the truth about medical error. Many
hospitals now have formal programs in which patients are told exactly what
happened, given an apology, and provided with some evidence that the
hospital staff is working to reduce the probability of that error occurring again.
Attention to the Inner Life of the Physician
We must acknowledge that we, the teachers of medicine, must attend
to our own inner landscape. Teachers who take resident formation seriously
find that both resident and teacher are changed. The journey to authenticity
is not being taken by the resident and faculty alone—the profession of
medicine is on the same journey. For that matter, our American society is
on a journey to authenticity as well. To the extent that our profession
discerns and tells the truth about healthcare, to the extent that it puts what is
good for the patient and the public before what is good for the doctor, and
to the extent that it is creative and generative—it is an authentic profession.
Authenticity in this sense is a verb, not a noun. It is not a state of rest; it
requires constant vigilance. Residencies and the institutions that house them
should be built on the bedrock of the intellect, will and imagination, and
they should offer experiences that strengthen and test these capacities.
Some Practical Steps
We must debunk the myth that our institutions are external to
ourselves. We tend to accuse others of our own sins; we tend to blame the
nebulous “they” for violations of standards that we, alone and together,
must defend. Palmer has stated:
[P]rofessionals, who by any standard are among the most
powerful people on the planet, have the bad habit of telling victim
stories to excuse behavior: “The devil (boss, rules, pressure) made
me do it . . . .” The extent to which institutions control our lives
depends on our own inner calculus about what we value most.
These institutions are neither external to us nor constraining,
neither separate from us nor alien. In fact, institutions are us. The
shadows that institutions cast over our ethical lives are external
manifestations of our own inner shadows, individual and
collective. If institutions are rigid, it is because we fear change . . . . If
institutions are heedless of human need, it is because something
in us is heedless as well.18
In our journey to authenticity as a profession, we must call institutions
to account as we call ourselves to account. We may pay a price; we may be
marginalized, demoted or even dismissed. Yet, the price we pay for
continuing to pretend that we are helpless victims, for living professional lives in
conflict with our deepest values, is greater. We must resist unprofessional
institutional behavior—not because we hate our institutions, but because we
love them too much to allow them to fall to their most degraded state.
Perhaps we should take seriously Palmer’s suggestion that we create a
system in which residents and other early learners could function as moral
agents. Like the canary in the coal mine, the residents could detect and warn
others when institutional conditions (relationships) are toxic to professional
values. They could keep us honest about how we are dealing with the sick.
This approach would require that we both listen to and validate the
residents’ feelings and that we train them to use the human heart as a source
of information. This, of course, is problematic.
Embedded in the higher education process is a systematic discounting
of the subjective; it is thought to be a source of bias and unreliability. Yet,
good physicians do more than simply pay attention to objective details.
Compassion, empathy, and deep respect are all dependent on truths
revealed by the human heart. Perhaps the heart, like the mind, can be taught
to discern truths. Perhaps when the heart is uneasy we should listen more
18. Palmer, supra note 4.
carefully and mine the information it is giving us. Perhaps a disciplined
approach could enable moral agency to develop.
Lacking a disciplined approach, we too frequently socialize residents
to cope with, rather than master, the systems in which they work and learn.
They live in the cracks of a broken system, but they are the glue that often
holds it together as they get things done. However, residents are renters and
not owners. They can identify system issues but do not feel empowered to
fix them. Coping with systems in which patient safety depends on
individual vigilance rather than design is wearing and dangerous, and we will fail
every hundred or thousand times—well below what we know is achievable
in other sectors of our society today. It also inhibits the formation of true
professionalism. The solution requires attention to group as well as
We have assumed that professionalism is an attribute of individuals
alone. It is not; it also marks communities. The assumption that the
doctorpatient relationship is a one-to-one relationship is flawed. In fact, it is more
like a twenty-to-one relationship—with several different types of doctors,
nurses and other health care professionals interacting with the patient and
each other in ways that are variable and frequently disorganized. Needed is
clarity for all about the roles, authorities and functions of the various
members of the team. Cultivating communities to discern and tell the truth to
each other, to enable and facilitate altruism, to make good promises and to
seek forgiveness, and to harmoniously integrate true hospitality into care
plans depends on paying attention to small group as well as individual
formation. It will help us respond to society’s call for respect.
Lastly, we must not stand passively by when our country violates
fundamental principles of social justice. Every resident physician encounters
the poor. Many academic health centers include care of the poor as part of
their mission and are frequently the backbone of such care for their
communities. Yet, widespread disparity exists across the larger society and even
within academic centers. The profession has been ineffective at best, and
silent at worst, about healthcare disparity. We would be well-served to have
a bias toward rather than against the poor—the larger society judges us over
time by our response to its needs.
Postmodernism: Can Medicine Offer a Corrective?
We live in a society in which truth is viewed as nothing more than a
social construct. Spin doctors, rather than real doctors, prevail. They can
construct a view of social justice that will serve their master. Medicine, in
its very nature, functions under a different set of assumptions. Rather than a
postmodern, socially constructed view of truth, doctors deal with things like
gallstones and brain tumors. Medicine accepts that there is a truth and that it
can be known, although sometimes with great difficulty. A gallstone is not
a social construct. A doctor may or may not detect it, but ultimately truth
trumps opinion. If we by habit discern and tell the truth, we can offer the
larger society an approach to truth that conforms to reality, rather than mere
social constructs that attempt to create reality.
Good doctors are humble; even the arrogant ones encounter failure.
Postmodernists lack that corrective and can become quite proud, marked by
hubris and convinced that they are right. Flannery O’Connor has said, “[i]n
the absence of the absolute the relative becomes absolute.”19 This is the
source of all fundamentalism: religious, political or other.
We cannot accept socially constructed views of social justice. This is
not an issue of conservative or liberal—it is deeper than that. We are called
upon to provide health care for all of our citizens; it is their due. In a society
with resources and know-how, failure to care for the sick is a breach of
professionalism. Further, we must respond to the needs of all of our citizens
in ways that offer an example for our young learners. They, too, will judge
our words and actions and grade us on professionalism. When idealistic
young people are told to adjust their values downward in order to
accommodate our accommodation, we have a problem. If we get this right, the
“crisis” in professionalism will fade, and we will have achieved the next
step on our own journey towards authenticity. We can deal with external
threats once our internal values are sound and our courage is found.
5. N.Y. State Dep't of Health, State Health Department Cites Mt. Sinai Medical Center for Deficient Care in Living Liver Donor Death , DOH NEWS (Mar. 12 , 2002 ), available at http:// www.health.state.ny.us/press/releases/2002/mtsinai.htm.
7. Beth McGlynn , Associate Director of Rand Health, Rand Corporation, Address at the AMBS Symposium: The Quality of Healthcare in the United States (Sept . 2005 ).
9. HANNAH ARENDT , THE PORTABLE HANNAH ARENDT 180-81 (Peter Baehr ed., 2000 ).
10. Letter from Paul O'Neill, former United States Secretary of the Treasury, to Author (Mar . 2004 ) (on file with author).
11. Common Program Requirements : General Competencies, supra note 6.
12. To view the Charter on Medical Professionalism, see Linda Blank, Medical Professionalism in the New Millennium: A Physician Charter, 136 ANNALS OF INTERNAL MED . 243 - 46 ( 2002 ), available at http://www.annals.org/cgi/content/full/136/3/243.
13. Palmer , supra note 4.
14. DEE HOCK , BIRTH OF THE CHAORDIC AGE 198 ( 1999 ).
15. JACQUES MARITAIN , AN INTRODUCTION TO PHILOSOPHY 112-13 (E.I. Watkin trans ., 2005 ).
16. See Dartmouth-Hitchcock Medical Center, Overall DHMC Performance Results , http:// www.dhmc.org/qualityreports/list.cfm?metrics= Overall (last visited May 7 , 2008 ).
17. Cystic Fibrosis Foundation , Care Center Data, http://www.cff.org/LivingWithCF/Care CenterNetwork/CareCenterData/ (last visited May 7, 2008 ).