Good afternoon everybody. I'm delighted to welcome you to today's session of on the professionalism seminar series. We are so delighted that our guest today is is Dr. Molly Cook from the University of California at San Francisco Medical Center. It's a real treat to welcome Molly back to the University of Chicago after a few years in California. Molly is really one of the premier medical educators in the United States. She helped found the General Medicine Division at UCSF, something that that I was involved in here at the University, although she's sort of a generation behind me in doing that. She went on to to hold the William Irwin Endowed Chair as Director of the Academy of Medical Educators at UCSF and recently was appointed by recently I mean this week was appointed Director of Education for the new Global Health Sciences Initiative that Dr. Haley DeBoss has organized out there in California. Molly has been awarded let me just see this twice received the Kaiser Family Foundation Teaching Award as well as the UCSF Academic Senate Award for Distinction in Teaching and in 2006 she was awarded the AOA Robert Glazer Distinguished Teacher Award by the Association of American Medical Colleges and in 2010 received the Career Achievement Award in Education from the Society for General Internal Medicine. You get the idea I could go on. Among all of her other achievements Molly Cook and David Irby were the lead authors on the book that came out last year called Educating Physicians. Many of you know about this book. This was a book that was commissioned by the Carnegie Foundation for the Advancement of Teaching on the hundredth anniversary of the original Flexner Report. The Flexner Report of 1909 which established the direction of American medical education for the next hundred years and made the United States the premier medical educator in the world for a century felt that it was time to rethink the the future of medical education and so the same foundation it's it's wonderful that these foundations last for a hundred years but the same foundation the Carnegie Foundation commissioned Dr. Cook and Dr. Irby to spend four or five years doing research and thinking and writing which led to the book called Educating Physicians a Call for Reform of Medical School and Residency. Fabulous book and actually David Irby was here about two years ago and spoke a little bit about the book. Now let me just tell you about the what might have been before I turn the floor over to Molly to talk about medical education and aspirational view of physician professionalism. Molly reminded me that she and I first met can I tell tell when sure in December of 76 when Molly was looking for an internship and she came to the University of Chicago and interviewed for an internship here which I promise you we made an offer of but elected to go to UCSF where she's been ever since so that that's the that's the might of bins had had we succeeded in recruiting Molly at that time for internship this book might have been written at the University of Chicago. So join me in welcoming Molly Cook. Let me just check and so I'm live. Thanks so much. It's really a joy to be here. What Dr. Siebler didn't say though it was I think hidden in the introduction by implication is that he was my interviewer and I I came within a hair of coming. I was it was just a magical hour. I'm sure it was meant to be one of those pro forma half an hour things and we may I say we have been friends ever since he has taken an enormous interest in my career and I have responded with great affection and admiration. It's really been just a lovely relationship. So it's a special pleasure to be here. I also appreciate the invitation to think a bit harder about professionalism in medical education. Actually I went on after my internal medicine residency and did a two-year fellowship supported by the Henry J. Kaiser Family Foundation with a concentration in medical ethics. I because of frankly as much as anything else timing and being in the Bay Area became an HIV physician. So I had a lot of opportunity to think about emerging bioethical problems in HIV. Initially very locally but relatively quickly I began to think about the global HIV epidemic which is a large part of how I've ended up with my brand new job. In people often ask me what surprised me in the course of wrestling really for four years with medical education and trying to come up with a synthesis of that might be useful going forward. And one of the things despite my background that surprised me was how central the concept of professionalism became to us as we thought about what medical education is really about. Now that's easy to say but kind of what do we mean by professionalism and what do we mean by saying that it's central. I'm actually not going to talk. You won't see the book again and I'm not really going to talk about the major findings of the book because I have used this opportunity to try and advance my thinking a bit. I took the word seminar literally so I don't have a huge number of slides and I would very much appreciate comment critique if what I'm saying is incompletely thought out or makes no sense whatsoever. I would actually really appreciate having that pointed out to me. I have learned a lot from constructive critique over the years. So one of the things that I began to realize as I thought about what I wanted to talk with you about was how much harm has been done or has possibly been done to the concept of professionalism by medical education over the past I don't know let's say 15 years and why do I say that? That's actually the center part of my remarks with you today but one of the things that was really striking so how do we do this book for me it was really sort of analogous to doing doctoral research. I must have read 2,500 papers like many physicians on sort of a self-taught educator and I've had the good fortune to be well received but I had never had the opportunity to devote a real chunk of time to saying what do we know about what works and what doesn't work in medical education and even backing up a step from that what do we know about how people learn and how might we apply these emerging understandings more effectively to medical education so this was a fantastic opportunity to really step back and and become educated myself about medical education but another piece of the effort involved fieldwork in contrast to Flexner who almost single-handedly visited every medical school then extant in North America in the course of about three years which is especially remarkable considering what the state of transportation was like in 1906-1907. We did not though we had airplanes at our command I suppose that the operation of medical education is so vastly more complicated than it was a hundred years ago we didn't begin to set ourselves out the goal of visiting every place but we did go to 20 medical schools and residency programs including some residency programs that aren't based in medical schools and we typically spent three days talking to teachers medical center leaders medical students residents and we using structured focus groups so we covered the same material in the course of these series of visits and what we heard about professionalism from the learners you know what we heard from the teachers was we take this very seriously here's our program here's our advising system here's here are our evaluation forms what we heard from students in general was kind of we think this is a crop we we uh we heard you know if your mother didn't teach you this by the time you were five it's way too late we heard a lot of conflation and this was uh I think just an accident of time with medical centers interest in patient satisfaction press gainy so the residents would complain a lot you know I got dinged by my clinic patients because they can't park and you know and so there was a fair amount of cynicism and pushback and and I I think that we're in fact a bit to blame for that residents and medical students for that matter didn't really understand what professionals was and I've already kind of given some examples to that of that and that's I think understandable it's it's what the social scientists like to call an ill-defined construct and people project a lot of different ideas of what they think is important onto it because it's not inherently clear what it is but I don't think this is a hopeless case and I and I hope we end up at the end feeling optimistic that that we can restore professionalism to what I think it's full importance but as I have already said we are starting with a understanding of professionalism among many learners that is reductionist and oversimplified I think and and I've already talked with you a little bit about that at the same time in the course of thinking about professionalism some serious critics have called to our attention that it may not be possible it may not even be a good idea at all to roll back to the clock to what Fred Hafferty has called a nostalgic view of professionalism and I I think there's a lot for us to learn here certainly this picture by Luke Fildes from the 18 late 1880s I believe is shown in about half the talks I've ever been to on the doctor-patient relationship there's something that really speaks to us about this doctor keeping vigil by the bedside of this very sick child and the distraught mother and the attentive father there in the background so a question is raised for me do we have to choose between this nostalgic view of professionalism or a dimension of professionalism and something else that may not have the the full emotional appeal that this does and again to to anticipate myself a bit I'm going to conclude by saying I think that this is not an either or this is I hope a we can do both situation but at the same time that our medical center leaders are focusing residents attention and to some extent students attention on patient satisfaction we actually have serious students raising the question of you know can this idea that many physicians walk around with of what professionalism is be sustained and supported in the 21st century at the same time that students feel or learners feel a bit put upon in terms of what their clinical environments are expecting of them in terms of patient satisfaction and performance they look at us and are often a bit disappointed by what they see now I could have represented this a couple of different ways but this map from 2008 was prepared by AMSA the American Medical Student Association which had begun in 2007 working on medical school conflict of interest report cards so they were asking the question no our faculty are evaluating us on our professionalism what do we find when we look at the at the schools we're going to in terms of policies that apply to faculty and this picture that the the oh the key doesn't I guess the key is really self-explanatory so 149 medical schools the green dots the light green dots are represent schools that have policies that am serrated a in terms of faculty conflict of interest dark green is b and so on to yellow which you can see predominates here is incomplete so the school either didn't have a policy had an incomplete policy or declined as many schools did in 2007 2008 to even tell AMSA what their policy was now things have changed so here's the same report card from 2011 2012 and for parents in the room a lesson you might take from this is that small doses of shame appropriately applied may not be the worst thing in the world because you can see that there are more schools are reporting they're far fewer incomplete there are way more a and b great there are many other anecdotes that I could tell from the field work about what students and residents saw as I'll call them professionalism lapses among their faculty but of course it doesn't matter what the anecdote is anytime learners see people exhorting them to do a who are then turning around and doing b that's a breeding ground for cynicism and we heard about that a lot another challenge for this larger conception of professionalism that I think many of us would really like to transmit to our learners is our approach to its assessment and in any ill-defined construct is going to be difficult to assess right and the more it the more we're trying to assess things that are not directly observable the more difficult the assessment becomes and the more uneasy psychometricians and people who are psychometrically oriented which includes as it should many people involved with high stakes evaluation but they become uncomfortable which has led the national board of medical examiners to actually invest a huge amount of money in what to me is this project is is annoyingly called annoyingly and correctly called assessment of professional behaviors and mbme is actually I'm a board member I should say and and about twice a year I say something in public about mbme that then leads me to write don melmick an email saying I said this and I'll resign if you think I should and he's very tolerant of me so he knows how I feel about this I mean I think the professional behaviors are absolutely the kind of rock bottom of what we should be concerned with and if we leave our assessment there because that's what we're comfortable with again what we're doing and it doesn't take a rocket scientist to see this is encouraging our very intelligent and responsive learners to adapt by looking like their professional which I think all of us would say is an entirely different thing than being professional so again this I'm trying to support my argument that in the course of trying to do something that is important the way that we have done it may have been really at cross purposes to our intention so another night I I actually looked for a title that I could use as a prompter put you in mind of this and didn't find one on my computer easily but while we're talking about this let me say a word about the work of my beloved colleague Maxine Papadakis who is a national if not international leader in this area of professionalism and assessment of learner professionalism and for anyone in the room who doesn't know Max published a very important paper in 2005 or 2006 in which she and colleagues and this was really hard work what they did they looked at practicing physicians who had been sanctioned by their state medical boards in three different states and then looked backwards sometimes as much as 40 years they reviewed the narrative comments about those sanctioned physicians in a blinded structured way and demonstrated this is basically a retrospective case control study demonstrated that there were characterizations of medical student performance that were strongly associated with the risk of state sanction decades later in practice this is very helpful work anybody who's had the unpleasant experience of sitting down with a medical student or a resident who needs to be talked to about a professionalism issue has likely heard that's so subjective the person who said that doesn't know me very well that person or you you just don't like me so the ability to connect students experience with their current assessments in medical school or residency with with the high stakes problems down the road is is an important that's an important counseling tool i think but fortunately the vast majority of students and residents get through their entire educational experience without running afoul of this kind of situation we have an absolute obligation i believe as educators to have systems in place to detect this level of problem and intervene and and remediate where we can't can and counsel people frankly out of medicine if we can't remediate these serious kinds of problems but that leaves 80 85 90 percent of our learners without any real compass as long as they're staying clear of this real badness uh we're we're not necessarily as educators holding up for them a kind of professionalism excellence to aspire to now fortunately i saw that uh i think it was i think it was vinny has spoken to you already about um old world professionalism in a new era and and we see that at ucsf i i know you see it here we see learners who despite the fact that we may be pretty much obsessed by the bottom feeders are still looking scanning their environment for people to admire for behaviors to emulate back to the to the question that i got earlier and and commitments to make but i would argue that we need to be doing much more for that large majority of learners who aren't going to aren't going to fall into the professionalism deficit or kind of lax category and help them uh understand what real um excellence looks like so i've finished making the comments that i wanted to make about why or at least some of the reasons that i think our students and residents um may have a reduced trivialized or inadequate conception of uh professionalism but i'm not going to put this in a somewhat larger context because our profession uh is challenged now as certainly all the physicians in the audience know and anyone who's done much reading or thinking about being a physician in uh 2012 has undoubtedly encountered as well there are a number of changes underway in how medicine is practiced how it's experienced by um physicians um and and how it's um managed by society that many physicians experience as an assault which is why i'm i'm showing a this image now again i don't think we have to think about it this way but many people do i have a um i'm privileged to have a leadership role in the american college of physicians and we hear this all the time from our members that sort of why is the college capitulating to whether it's pay for performance or any one of a number of changes that are clearly well underway um in american medicine and our learners um see this as well so one of the things that that i think is very interesting um and has holds as much opportunity as challenge if we can figure out how to work with the opportunity is that physicians are no longer in control of the high knowledge that um that is the the sort of factual and conceptual basis of medical practice now if you read about the sociology of professions and again people who are regular attendees at this seminar have heard from a very uh skilled sociologist about this the the basic concept from the non sociologist is that there is a body of privileged knowledge and skills that is restricted to the members of the profession in exchange for self-regulation and and service to society but the idea that we um are the exclusive portals uh for the public to this information that's long gone again um ACP members uh many of them rebel against this why why are you not fighting against expanded scope of practice for nurse practitioners why are you not um saying very critical things about minute clinics if there comes up in any number of ways but this horse is way out of the barn so i love this slide uh Hugo Campos is a i think he's an it person in the east bay where i live uh unfortunately he has a hypertrophic uh cardiomyopathy um and for that reason he has a implantable implanted uh cardiac defibrillator and he has been in now a several year battle with the FDA and his device manufacturer because he wants the raw data from his device and people say his website is actually very entertaining people say well that would be a hip of violation that's right but the the long and short of it and the thing that clearly people say most frequently is you wouldn't understand it and he says give me the data and then we'll see know if i don't understand it i'll ask here so he has formed a users group being a good it guy and he has learned how to hack into his device so and there's just going to be any number of examples like this where where people are basically crowd sourcing um information uh about their own about the conditions they have or the family member has and uh doing what they want with that information so this is a done deal and we're going to need to figure out how to interact with people like mr campos in a professional way because we cannot roll back the clock to a time when no physicians could read and patients couldn't um or some more modern but still highly asymmetric relationship between patients and physicians so i already mentioned p for p uh if i had thought of it in time my colleague on the board of regions of the acp uh faith Fitzgerald who here knows faith Fitzgerald a couple of people do well she would have had me have a circus seal with a ball on the end of its nose to go with this uh slide she is as are many physicians profoundly insulted by just the term uh pay for for performance i mean her argument being that it ought to be a fundamental attribute of physicians that we perform if that's what you want to call it at the highest level of our capabilities as a matter of course but this is another horse that's well out of the barn and i as somebody who also speaks about cost of care at this point i think we need to entrain really any mechanisms we can to try and uh get um clinicians across the board more focused on quality efficiency patient outcomes uh and cost consciousness but this is another uh secular trend that many physicians are experiencing as a kind of a deprofessionalizing trend and then there's bad physicians and there's no dearth of um access to detailed information uh uh no sort of horribly fascinating information about bad physicians now there have always been bad physicians i have no doubt of it but the ability to learn about bad physicians is vastly enhanced in the digital era and i have to say as well the opportunities for physicians to be bad on a spectacular scale um is also uh much greater than it was when no if i were a complete venal quack my little village had to deal with it but it would have been hard um it would have been impossible until 1965 uh to uh bulk medicare out of three hundred seventy five million dollars the and you're you're not surprised that uh if not the public in general the public is represented by our legislators are completely scandalized by this kind of thing and use it as evidence that we need more oversight and more regulation and you you really can't blame them so i'm wrapping up now uh i had not encountered this paper until i got i was preparing to uh do this talk so the title is hero or has been is there a future for altruism in um medical education and actually these uh authors bishop and reese basically basically conclude that there's not um and i'd ask you for the purposes of this talk to consider altruism a key dimension of this old fashioned um professionalism that fred haffordy suggests that we may be nostalgic about and and i will acknowledge that uh when the um physician charter uh was promulgated if that's exactly the right word uh in the early um part of the first decade of the century and and was being talked about among various stakeholder groups uh medical students and residents um rated the altruism principle their least favorite so the the that was basically um expressed as putting the needs of patients ahead of your own and uh this generation of medical students and residents not not every last one but many people said that's not something i'll sign on to and it the the main reservation had to do with well some of it had to do with kind of practicality or practical application what do you what do you actually mean by that and how far does uh that principle go in expecting me to suppress my own needs and desires for someone else's but there's also been clearly a significant secular trend within medicine as well as more broadly in terms of promoting work-life balance um a personal kind of wholeness we should take time for ourselves and our families away from patients we should recreate in various ways that are important to us and having sat in on some of these groups that's what learners say they're the the needs of other people whether they're people actually in my panel or people who could be in my panel or people in my community with health problems it's always going to exceed my ability to meet them and certainly my ability to meet them and accommodate other legitimate interests that i have so so what do we do uh with this situation where learners have a reduced image of or concept of professionalism the profession itself at least um is uh experienced by some physicians uh as under assault is there still a role for what i'll call a capacious concept of professionalism and what might that look like in uh 2012 and and beyond so here's our city on the hill intending to convey to you that i think that this is actually not just a critical task for us now but actually quite an exciting one as educators uh reworking our understanding of professionalism so that it does what we want it to do for the profession so our learners understand it and can aspire to it so i i'm going to go back for a second i will argue and i don't think i get much objection to this argument that people still come to madison as students and residents by and large with an intense desire to help people i had a wonderful dinner last night with a number of you uh who are working as i am about to do in the area of global health and i think that global health and the enthusiasm for global health which you know it it has a few sort of underbelly issues but in general is a manifestation of how much people want to help and the magnitude of problems that people are interested in tackling as they begin their medical studies so these are not people who are saying i want to learn to look like i'm a professional these are people who are saying there's really bad problems whether whether you're talking about the slums of kampala or migrant workers in fresno where where i actually do a fair amount of work these are these are gnarly problems and there are many forces working against their resolution but i want to be part of the solution so i absolutely don't think i think that's what we need to capitalize on and we need to hang on to this big idea that may not be complete maybe a little in co-aid it may not be completely formed as our learners bring it to us but we shouldn't reduce it in the course of helping them specify it we should keep it big in addition to uh so right i actually didn't i thought i had a different slide here but that's fine there is a concept that i'm now going to borrow from from the so-called learning sciences it used to be uh well it still is if you are a sort of a cognitive classic cognitive psychologist that you think about learning in terms of taking whether it's facts from your brain or concepts from your brain or schemas from your brain and and teaching is the process of getting them into somebody else's brain so there's the teacher and the learner and the and teaching is about this uh transaction a i think much more it's certainly a more modern conception and it to me a more interesting conception says that knowledge is thickly distributed in a number of environments and particularly and specifically because that's what we're talking about the medical environment there's all kinds of information all over the place some of it's in other people but some of it's in forms that we have to fill out the the that uh those forms may request information they structure our approach to problems um we've just implemented epic and we're personalizing or customizing epic so that uh for a particular kind of consultation i'm a general internist i need to supply the rheumatologists with some information and the form reminds me that uh if i'm asking the question does this patient have rheumatoid arthritis it will help the rheumatologist if i've drawn a ccp and that information if i forget as i am want to do the form reminds me and that's an example of information that's distributed in the environment so this is this is actually not the best graphic i have for this but this is a activity system schema uh activity theory was developed in the 30s by several russian psychologists and really all they're doing here and this has been customized to apply to dentists is pointing out exactly what i was just doing that there's information in the dental instruments about um how you are how you ought to use that instrument as a for example so there's information everywhere our junior colleague writing the book Bridget O'Brien said to me one day if it's true that cognition or knowledge is distributed in the environments in which clinicians work might it also be true that professionalism is distributed in the environment that in which we work and learn and it was a it was a wonderful insight of course Bridget turned out not to be the first person to have had that insight but it was a very important one is Dean Levinson here oh i i so admire this paper this is a lovely piece of work taking Bridget's observation um and also a bit of Fred's impatience with the nostalgic view of professionalism and saying no can't we think about this in a more complex way now you know i don't know when the learning sciences were being developed if if objectors said if you think about knowledge being distributed in the environment then it's not important what knowledge an individual has in her head but certainly nobody says that now they're they're both important and some of the sort of in the mediating skills are maybe even more important do i know whether what is in my head is adequate and if it's not adequate do i know efficiently how to get out of my head and and get the information that i need to apply to the case and i think that that that way of thinking exactly applies here that we want people to carry around their own strong individual professional values but we have to recognize that people work in complex environments in relationship and and the environments and the relationships impose very strong influences for good or evil on what people do in a particular situation all of this is again as the learning scientists like to say situated we're really talking about decisions people make and actions they take in a particular context these are not this is not an abstraction and i'll close by using my beer bottle here to tell a story from our fieldwork you can if i tell the story my guess is that there are going to be people in the room who can guess where this happened we were doing a i was doing a focus group with internal medicine residents and i was going through the interview schedule and i got to the professionalism part and there there's already been some very interesting things in this focus group about how these residents talked about professionalism but i said so what does it really mean to you and one of the residents told a story about a resident sort of just before him who this is a this is like a quartinary or beyond that referral site so there many people come to this place from all over who have been told by their physicians where they live this is not a curable condition so this is a a place of last resort and this resident about whom the story was being told was taking care of somebody with a widely metastatic malignancy who had had been told at home this is not something that we can cure we can palliate we can do all the good things that we're supposed to do we cannot cure this so he arrived at the place that we were visiting and this resident was assigned to take care of him and in the course of chatting with the patient the resident had learned that one of the things that he missed the most about being at home with this horrible illness was a particular favorite beer and so the resident took an afternoon off and found this beer and brought it in and the resident telling the story said you know i'm sure there's some rule against that but to me that's professionalism so we i i i i put this story the story is in the book and somebody reading the book said you know actually that was me i did that but the that person had finished the residency program like 15 years earlier but this story is so in the culture at this institution that the resident talked about it as though you know this just happened uh so i i i love this story you can actually do a whole lot of other things with professionalism and what it means and knowing when to break rules and so on and so forth but what i think we're looking for is a way to build back in these aspirational dimensions of physician performance that many of our learners come to us already holding in high regard this is david stern and louise arnold's i call it the temple of professionalism their intention in drawing it this way is that there are foundational elements of ethical and legal understanding communication skills and so on and so forth where you can say you pass the verticals are things that we're never good enough at they are the uh the aspirations that support our desire to tackle these really big problems recognizing that most of the time you're not going to entirely fix the really big problem and as i said i think it's that capacious view of professionalism that our learners bring us and that we need to build on so i have arrived at the end i think we have a few minutes for questions or comments i realized people have one-o-clock issues some do yeah marshal yeah i'm just gonna share a story from your past this least from my past for your past so that's the message that you say set for the late 80s and the last month of your fourth year it's a great course of that time which was sort of a some ways of preparation for internship you review some clinical issues but then there were special topics i remember the month was a great month the only less rash remembers yours on when you make a mistake you know i don't know if you still do that or not in terms of that that topic but you know in some ways like through medical school residency professionalism was basically finding role models you know but it was hard to quantify then in terms of actual training and throughout your talk i mean you raised a lot of issues in terms of the challenge of professionalism defining it but your constituency actually avoided talking about how do you increase professionalism within trainees and so you know are we left in terms of you know hopefully you have great role models like you know my story at UCSF or you know what have you learned in terms of the recommendations you make then for us here trying to teach professionalism no and that's uh i got farther than i did in the book but i'm still kind of uh working on this issue i i absolutely well let me start with something that i think is a destructive force that is easily addressed i shouldn't say easily but can be addressed if uh and i've done this experiment a bunch of times uh you ask an audience of physicians to recall the or a most powerful um professionalizing experience in which they really got some uh strong insight into what it means to be a doctor in a good way most of those things happen at night if you if you ask people did it happen during the daytime or did it happen at night most of them happen at night and i think there's a whole bunch of reasons why that is um and some of it may just be what people recall but they were it's important if that's what they recall but that's what they recall and so there's a lot of concern about what's going on and now the interns don't spend the night in the hospital uh so so does that mean that they have a year without those kinds of opportunities i think continuity is a a extremely powerful uh professionalizing force and we have allowed for a variety of reasons our learners experience to become highly discontinuous uh so i i think that building back continuity uh is critically important and we see examples in the third year clerkships that uh our longitudinal integrated clerkships every place that's doing that has amazing stories about what students did out of their strong connections with patients over time i also think that strong i very much appreciate your story but in general i think that strong connections between learners and teachers over time are really important as well so that can be supported in the organization of clinical work in uh at UCSF as a number of places have done we have brought into the curriculum a number of activities that students come to medical school caring a lot about and we have if you'll excuse the uh ugly word we have curricularized those global health is one of them and it's is intensely popular and that's another way of putting learners in proximity with more senior people who are committed and i've used this word a lot with fully with full intent who are committed to the things that they're committed to and i don't mean you're a very seasoned teacher i don't need to say that i think preaching about this stuff just it it does very little good and mostly annoys the learners it's letting them have the opportunity to do authentic work side by side with people who can guide and mentor them and i think you could clear out a lot of space in both medical school and residency certainly places like the ones that we're fortunate to work in with the caliber of learners that we have we you could clear out a lot of room without interfering with the acquisition of the clinical excellence that's to me foundational i mean i'm a practicing clinician so i think in the end you know you don't have much of a doctor in that sense if if a person is not very strong clinically but there's room to do what do other things as well but i think your answer to marshal may have been the answer to the question i'm about to raise but early in your talk you suggested that medical educators and medical education may have done considerable harm to medical professionalism and you pointed out your observation which i i must say i share of the of the enthusiasm that the teachers bring to teaching it but the cynicism that the learners bring to learning about it and the questions that they raise about is is this a teachable skill professionalism and and i thought you were getting sort of to get at that answer it went when you said that for the kind of learners that we work with there might be a lot of room that could be cleared to permit the legitimate kind of professional development and modeling to take place just did i get it right or yeah yeah now i i don't know if you when you're talking about our enthusiasm for teaching you're specifically talking about teaching of ethics well i was talking more i think i was talking more generally teaching of medicine ethics professionalism yeah i mean that we're enthusiastic in what we want to pass along well so so i mean i do think that there are some generational trends underway that again we you can't roll back the clock and and uh you hear a lot about you know they're just not the way they used to be they they they're they won't work hard they're this they're that that's just i mean that's sort of to me an unhelpful approach i am working with a student now who has raised some issues for me uh in terms of effort and initiative and when i talked with him about it you mean he has a a lot a number of gen y characteristics if you sort of believe in this slicing at all but you know he said i have got a very rich and complicated life and i don't want medicine to take it over so i said fine i get that i don't care if you want to work six percent time that's fine with me but that piece of the of your life that is medicine has to be done to a certain standard and i'm i'm not seeing that now and this is pretty typical of gen y again if you believe this stuff when i told him that he told me some things that were disappointing about me it's okay and but then he fixed what i was talking to him about so uh people can need some people can need some very clear guidance about what it is that we're expecting since i projected onto your question ethics teaching i it seems to me that you absolutely need to to cook into the student's own experience so i teach in our third year intercession program the students come back from their clerkships all over and bernie lowe always arms us with these paper cases and i i i refuse to use them and i tell the students at the beginning i'm not going to use the paper cases and we will just sit here in silence if you won't share some of the things that you've seen happen and there's always quite a long silence because they don't believe me you know they think they can outweigh me um but then someone will say well i have a case but it's not very good so i mean they bring in these conceptions about what a good case is and we always get a great discussion and it's better for one practical reason which is with the paper case you know there's nobody there to say you know that the husband really rubbed me the wrong way there's there's just not enough reality to them um but the second thing is well it's really the same thing the the case that the student brings is bothering them somehow and and that's what's i mean that's what's teachable that's what i learned from al and kasua straight is that really is what you're looking for i was just curious when you were going through the country were there any differences between institutions that were much more smaller and primary care based much more clinically based institutions and tertiary care centers just having trained at both types of institutions sometimes mentorship is a little bit different when it comes from somebody that is on a strictly clinical path that maybe has a clinic much more often and you and you see them on a more continuous basis versus people that have much more segmented care of patients and and much more focus on non-clinical path so um overall the places that have the most challenge um doing this really well are places like the one where i work big academic health centers they have very complicated and often somewhat conflicting missions which the particularly the residents i i think students don't perceive this as much because they're a bit insulated but one of the surgery residents at um at ucsf said one day you know we talk about we're a medical school and we've got uh now we talk about having four key missions um teaching clinical care research and community service which got crammed down leadership's throat at a retreat about 10 years ago but the the the surgery resident said no we're really here so the faculty can do their research and he wasn't particularly hospital he was just realistic and they mean they see faculty doing their assigned uh teaching hours and then you know roaring back to the lab or wherever it is that they're going who who thinks they know where the beer story comes from just guess wisconsin well close it's mayo and mayo is it's a it's a one-off place really we didn't see any place like it but if you go around and look at medical education and say what's your mission statement they all basically have the same mission statement you spend three days and you know i often wanted to rewrite their mission statement your your mission statement is not your real mission here's your real mission at mayo they they they still um uh say exactly what the brother's mayo said which is it's all about the care of the patient we got to it got to be a joke by halfway through the second day how long would we be in a focus group before someone said it's all about the care of the patient and i i swear you could have done a focus group of custodians and they would have said it's all about the care of the patient so that they had a consistency of vision uh that that everybody picked up on but that's atypical and it's it's um very atypical at at the really big academic uh health centers like ours now that doesn't mean you know university of washington i don't usually do this but university of washington is interesting because they manage a pretty bimodal mission uh well i asked a third year student who wanted to be who i'm i'm sure will be an academic neurosurgeon how he liked being sent out during his third year as part of the wami program to uh you know a little hamlet in northern Idaho 1200 people to do family medicine and he said well that's this is where my patients are going to come from they're not all going to come from Seattle and i need to understand what the life is like of the family physician who's going to take care of my brain tumor patient when i send him home so he had gotten that our students when we try to send them to fresno say you know i don't like it here you know and you know i i i can't go to my favorite i'm being a little me i'll stop we often talking about altruism that i try to understand it's always a patient come first to me this looks like it does my wife come first to my mother to me it is both is first yeah patient and i come first both of us proportional based on our needs so for example if i understand the individual rights and justice then um then i could handle both i am not sacrificing anything for patient if it's say i am a surgeon and i have an opera teacher then tonight a patient comes that needs operation yeah i'm not sacrificing anything if i stay because it's a part of my profession i enjoy it so the patient here is not first is a part of my profession on the other hand if there is really no need that i admit him tonight then i get this opera teacher the night tomorrow it's just it's fine then i am first so we are not really sacrificing ours because we understand our duty what is our duty in relation and therefore i don't understand who comes first and who comes second that's what i am yeah yeah before your answer i just want to tell you a story there was a cardiac surgeon here many years ago but but you would remember him if i told you his name who had opera tickets and whose wife was a great opera buff who was doing a patient of mine on a night when a particularly important opera was going to be sung and i i went into the or and the wife's voice is coming across the intercom saying where are you we're going to be late for the opera and my voice is right there saying stay here this is the case this is where you belong and so you had these two these two voices with the opera tickets in the middle so i was a little unfair to the authors of the no altruism hero or has been paper because i said that they really said it's a has been concept and they don't quite say that what what you did telling the story is you contextualized that question and and that's i mean that's what we need to be teaching sometimes the patient does come first and and sometimes you have to give up something you would for sure like to do but that's i mean that's a knowing when you don't have to do that and when you do that that is a sophisticated manifestation of of professionalism and it does get to this fundamental point that we did i again i was i was just in reflection so struck by the attention we ended up paying to having our learners become become physicians not act like physicians you know you're saying you know i just i know that difference now so you're not it's not a rule it's part of who you are and that's what we're aiming for so thank you very much i really appreciate the chance to talk with you