Monday, September 13, 2010

Humility



I sometimes wonder if we spend too much time talking about professionalism. It is not that I don't think we should promote professionalism. Of course we should. But many discussions of professionalism descend into overly academic and scholarly treatises that end up obscuring rather than clarifying the values such discussions hope to promote. It may be a mistake to overly intellectualize core values. I sometimes wonder if we would be better off focusing on core values and thinking about how to promote and reward those values.

Humility is one of those core values, and a wonderful essay by Dr. Jack Coulehan in the Annals of Internal Medicine wonderfully discusses the virtue of humulity and its importance in medicine. This brief 2 page essay can be read in 10 minutes, and it will be 10 minutes well spent.

Coulehan has a three part definition of humility: (1) unflinching self-awareness; (2) empathic openness to others; (3) a keen appreciation of, and gratitude for, the privilege of caring for others. Coulehan contrasts humility with arrogance. In many ways humility is the opposite of arrogance.

Medicine would be well served if we had more humility and less arrogance. This is especially true in academic medicine. Coulehan notes that while medical education once promoted collegiality and shared values, it now promotes egoism and entitlement.

Too often, academic medicine encourages and rewards self-promotion and egoism. Our students notice and learn from this hidden curriculum and it clearly must lead to behaviors that are not good for patients.

As Coulehan notes, humility is not inconsistent with pride in accomplishments and achievements. But, when we have too much egoism and too little humility in our training environments, it promotes a cultural in which leaders and teachers start to see themselves as the center of the universe, rather than their students, colleagues and patients.

Good, humble leaders believe they are there for the benefit of those they lead. Arrogant leaders believe their trainees and subordinates exist for their benefit. I suspect these behaviors are contagious and a key determinant of whether one will develop into a humble or arrogant leader is which of these of attributes dominated the enrivonment in which you trained.

Coulehan's call for humility presents a central challenge for medicine and our academic training environments. More humility and less arrogance will do much to improve how we care for our patients, teach our students, and conduct our research.


by: [Ken Covinsky]

4 comments:

Anonymous said...

We currently teach students to inspire confidence in their patients and colleagues by acting and speaking confidently (regardless if they have any confidence). In addition, confidence allows one to make decisions when one might otherwise have "analysis paralysis" under uncertain circumstances. Does anyone have practical suggestions or an example as to how to teach confidence to medical students, while still promoting humility and discouraging arrogance? What would a humble oral presentation, or humble interaction with a patient look like? Its hard to imagine rewarding humility on the wards . . .

Barbara said...

I have found working in Palliative Care brings home these very thoughts of humilty. Being present for the patient and feeling gratitude to share this part of the journey with them. Humilty brings back the human compassion for those we serve.

Eric Widera said...

To anonymous - humility and confidence can be role modeled at the same time. An example comes from Kerry Patterson's and colleagues book Crucial Conversations: Tools for Talking When the Stakes Are High

"We mentioned that the key to sharing sensitive information is a blend of confidence and humility. We express our confidence by sharing our facts and stories clearly. We demonstrate our humility by then asking others to share their views."

Anonymous said...

With regards to anonymous’s questions about teaching professionalism to medical students, here is an example of how it is defined and operationalized on the UCSF School of Medicine website: http://medschool.ucsf.edu/medstudents/index.html#profdev scroll to bottom and click "professionalism." The three pages used to describe professionalism and measures in place to promote it.

We deter medical students from unprofessional behavior by the "Professionalism Form,” a black mark on the student’s record that can negatively affect their application to Residency. Students can receive the "Professionalism Forms" for "Unmet professional responsibility," defined as: "The student needs continual reminders in the fulfillment of responsibilities that are essential to being a medical student at UCSF.

Alternatively, UCSF incentivizes professional behavior via the evaluation process on the wards. After observing a student rotating on their service, any Attending or Resident can use a 9-point scale to judge the student's professionalism across four domains: responsibility, self-improvement, dealing with patients and families, and relationship with the healthcare team.

The importance of identifying and disciplining medical students who display unprofessional behavior is supported by data in a case-control study done by Papadakis et al. published in New England Medical Journal (2005), "Disciplinary Action by Medical Boards and Prior Behavior in Medical School." This article describes how doctors who received disciplinary action from a State Medical Board, were much more likely to have displayed problematic behaviors earlier on as medical students, than doctors who did not receive disciplinary action from a State Medical Board. It’s clear that as educators and administrators, we need to refine our ability to identify and measure unprofessional behavior in our medical students so that appropriate discipline and remediation may be sought early on in their training, when there is the greatest hope for change.