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Vol. LXII, No. 23
November 12, 2010

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Professionalism in Medicine
Good Practice Is More than Facts, Figures, Inui Says
  Dr. Thomas Inui  
  Dr. Thomas Inui  

In medical school and in the academic years of a research career, students are expected to learn and retain myriad bits of knowledge, facts and information designed to make them better doctors.

But one of the hardest things to teach, and what counts in a successful career, is how to be a professional and retain a solid moral grounding, says Dr. Thomas Inui, professor of medicine at Indiana University School of Medicine. He visited campus recently to offer a Grand Rounds for Fellows lecture titled, “Moral Development and Professionalism in Medicine: Learning to Use Two Traditions of Open Ocean Navigation.”

Professionalism may seem like a simple concept, he said, but in medicine and biomedical research, some situations can be tricky. However, regardless of who defines characteristics of a good doctor—the Association of American Medical Colleges, the National Board of Medical Examiners or the American Board of Internal Medicine—certain terms recur.

“We have a larger vocabulary that we could use, but we use these same words again and again. They all begin to sound like the Boy Scout Law,” Inui said, referring to the organizational creed whose main principles—being kind, loyal, trustworthy, brave, cheerful and clean—are intended for scouts, but could easily be applied to a practicing physician or clinical researcher.

“On a busy day in the clinic, being helpful, friendly, courteous, kind and cheerful are all good things. Patients do appreciate them. They see them as attributes,” he said.

By regarding what it means to practice medicine or research in this way, and by using idealistic terms such as these to describe the profession, Inui said, it suggests that we place the good practice of medicine in the domain of morality, humanism and perhaps of spirituality.

“In this way, we express a view of medicine as a moral enterprise, a virtuous activity,” he said.

He asked the audience to discuss in pairs or trios examples of professionalism at work or the cringe-inducing lack thereof.

Some said they had seen good examples in office settings or labs and others testified to situations in the clinic that left them shaking their heads.

“You all have an idea of what professionalism is,” he said. “You can recognize it when it’s there and when it’s absent.”

It’s this kind of sharing through stories that forms the backbone of a program Inui and colleagues installed as a teaching tool at Indiana. Prior to his arrival at the school some 7 years ago, the atmosphere at the school was demonstrably clouded. According to Inui, data accumulated through exit surveys found that students were disillusioned and cynical, almost resigned to the idea that going through medical school was more about competition and outlasting classmates than about trying to be the most effective, compassionate doctors possible.

Inui found that professors were generally not engaging students in ways that made sense to them.

He used a quote from theologian Paul Tillich to describe what was happening at the school: “The fatal pedagogical error is to throw answers, like stones, at the heads of those who have not yet asked the questions.”

The teaching staff had to make changes, ones that meant their students would, like Inui’s Grand Rounds audience, participate in defining and identifying what makes a good doctor. In effect, the professors needed to teach students the principles of navigating an ocean of ethical and moral dilemmas.

Inui offered the metaphor of two ancient modes of high-seas navigation: the European method using sextants and stars and the more sensory-based Pacific Islander method of observing winds and currents to guide passage. Some balance of the two modes—the empirical and the intuitive— is optimum, he suggested.

For a number of years now, Indiana’s curriculum has included a forum where students share experiences that have illuminated something about their chosen profession. Most times, these are intangibles that can’t be measured or reflected in a letter grade. Instead, they are lessons reminding them that to be a doctor is also to be a human being, said Inui.

Illustrative examples are shared in groups and discussed so that students get a chance to think about how they may act in similar circumstances. The program has fundamentally altered the way many students see their role as future doctors.

“The question is: How will you make your choices?” Inui said. “Are you prepared for the complexity of the world? Are you prepared to muddle through while staying connected to your fundamental values in complex circumstances? You will be judged by what you choose to do again and again in these situations—this is what is meant by character.”

Guest speaker Inui found a lacking culture at Indiana University School of Medicine and set about addressing its shortcomings.  

Guest speaker Inui found a lacking culture at Indiana University School of Medicine and set about addressing its shortcomings.

Further, intensive research efforts have pinpointed a number of specific genes involved in alcohol dependence as well as their functions. Foroud said this work may open the door for new treatments and medications tailored expressly for the individual, leading to personalized treatment for alcohol dependence.

Although it has long been known that alcohol alters behavior and perception, neuroscience has vastly increased the understanding of how alcohol affects the brain and its functioning. Dr. Edith Sullivan of Stanford University School of Medicine described how alcohol use, both short- and long-term, can have serious effects on the structure of the brain and how it processes information, leading, in some cases, to severe mental disabilities.

Dr. Robert Anthenelli of the University of Cincinnati College of Medicine described how alcohol use and abuse often are intertwined with other co-occurring mental health disorders such as anxiety, depression or post-traumatic stress disorder. Some of these effects have been traced to the body’s responses to stress; those responses vary considerably in men and women. Co-occurring disorders are an important area of inquiry as they present challenges for both diagnosis and treatment. Therefore, research in this area is vital to successful treatment for many individuals.

The brain is not the only organ negatively affected by alcohol. Early research linked alcohol use to damage to the liver, the organ responsible for breaking down alcohol and helping to eliminate it from the body. Recognizing liver damage from alcohol was just the beginning of our understanding of the medical consequences of alcohol abuse. Dr. Pranoti Mandrekar of the University of Massachusetts Medical Center summarized the latest findings on the effects of alcohol on the body, including the liver, heart, gastrointestinal system, as well as the immune system.

A common misperception from the past was that alcoholism was found primarily in middle-aged men. Research now shows that alcohol dependence is found in people of all ages, both genders and a variety of ethnicities, and that the highest prevalence of dependence is found among those ages 18-24.

Dr. Michael Windle of Emory University discussed the problem of underage alcohol use. Particularly troubling is the effect that alcohol may have on the developing brain. Studies show that the brain continues to develop into a person’s mid-20s, and the consumption of alcohol during this time, particularly frequent binge drinking, can affect both memory and behavior.

Dr. Jennifer Thomas of San Diego State University described how the fetus is at risk for serious consequences when mothers drink during pregnancy. Exposure to alcohol prenatally may result in varying degrees of physical, mental and behavioral problems. Research is now helping to identify specific interventions that can mitigate these problems.

The broader effects of alcohol on society were addressed by Dr. Robert Voas of the Pacific Institute for Research and Evaluation, who discussed how alcohol consumption is related to public safety. Research has helped to shape policies and laws that have had significant positive effects. These include raising the minimum drinking age to 21—a law that significantly decreased the number of traffic deaths among young adults—and drinking-and-driving laws that protect all ages across the nation.

In closing, Warren thanked the speakers for their “truly outstanding presentations that directly demonstrated the explosion of the knowledge in the alcohol field over the past 40 years.” Importantly, research is being translated into practice. Increased knowledge of genetics, neuroscience and other fields has led to new medications and treatments, offering hope to people who suffer from alcohol abuse and dependence. And advances in our understanding of alcohol’s effects—both harmful and beneficial— are helping to improve public health.NIHRecord Icon

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