Year : 2017 | Volume
: 5 | Issue : 2 | Page : 145--153
Preserving the passion and the attractions of clinical medicine: Shaping the medical students of the future
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
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Shelley BP. Preserving the passion and the attractions of clinical medicine: Shaping the medical students of the future.Arch Med Health Sci 2017;5:145-153
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Shelley BP. Preserving the passion and the attractions of clinical medicine: Shaping the medical students of the future. Arch Med Health Sci [serial online] 2017 [cited 2018 Feb 20 ];5:145-153
Available from: http://www.amhsjournal.org/text.asp?2017/5/2/145/220817
“A good teacher can inspire hope, ignite the imagination, and instill a love of learning”
“An academic who only presents facts is not a teacher; a teacher is one who nurtures the learning process and thereby modifies behavior and patterns of thinking for a lifetime.”
”Vaidyo narayano harihi,” the Sanskrit sloka meaning that a true doctor (healer) should be seen as a form of Lord Narayana, as an incarnation of God, is the traditional belief among the public. Is this idealistic and moralistic view of medical professionalism valid in today's dynamic and changing climate of modern medical practice? Perhaps being cognizant of the realism of modern medical practice, the pragmatists would voice that the time has come to redefine the sloka. During my travel through the journey of medicine, I have observed a phenomenal change that has transformed the moral enterprise of medicine from a mission into a profession, now eroded into an occupation. Why did medicine evolve in this trajectory, why is there a metamorphosis in the generation of doctors today, and why doctors leave the medical profession for new pastures that really excite them?, Why is medical practice largely characterized as unethical today? Will this changing phenotype of medical doctors and the transformed climate of academic medicine pose a threat to the future of modern medicine? I express my concern over the attrition in “professionalism” in medicine and fear that the medicine of tomorrow's doctors and the future medical workforce will be at tremendous risk if the collectivistic pursuit of “passion for excellence, professionalism, and empathetic medicine” is not fostered in medical schools.
The transformation in academic medicine may be reflected by revisiting the quote of Kenneth M. Ludmerer, a medical historian and educator, “Medicine is, at its center, a moral enterprise grounded in a covenant of trust. Today, this covenant is significantly threatened.” Today, at the core of the heart of medical practice and its moral contract with society, I sadly acknowledge that genuine professionalism is indeed in peril.” Thus, medicine is increasingly fragmented and dehumanized. Doctors no longer see a patient as a distinctive human being, instead as a set of deranged organ systems based on reductionist approach. The distressed patient as a “whole” is absent in this equation of healing. Unfortunately, commercialism, commoditization of medicine, and consumerism have changed the patient–doctor relationship as something less than a fiduciary relationship. I would reiterate that medicine at its heart must have a “human touch” and cannot be governed by “cold science” alone.
In this healing profession that should be oriented on a relationship-centered care, I would unequivocally state that one of the quintessential virtues of a clinician (healer) and his/her art of doctoring is the uncompromising character, the deep conviction, and interest in humanity. I would call this as “emotionally inclusive care” that is “relationship- and patient-centered” which is undoubtedly pivotal for evoking quantum healing and positive therapeutic healing outcomes. However, today's trajectory of medical education and training is one that fosters “hi-tech, no touch medicine.” However, I am not a skeptic of the tremendous leaps and advances in modern medicine, but an optimistic pessimist, recognizing that the “glass of our medical school training” is however still half empty. Have we lost something of the art of medicine in a headlong rush to embrace the reductionsitic science of medicine? Are we as medical educators “polishing” medical trainees from the “outside” with technocratic medicine and not from the humanistic “sanctum sanctorum” for whole-person positive healing outcomes?
I see a vital quintessence vanishing from medicine, it's not compassionate, and the art of healing is lost; medicine has lost that special trust that bonded the doctor and patient (physician–patient relationship), and this has been barter traded. Healing is replaced by treatment and the art of listening by technological advances/gadgets. It is disheartening to take note of this erosion of Oslerian medicine to the current dehumanized, dis-empathetic, uncompassionate clinical and the professional encounters characterized by a distinct “social-disconnectedness,” a “detached concern,” and “heartlessness.” Akin to the story of “The Parrot's Tale/Training” by Rabindranath Tagore, are we as medical educators neglecting the humanistic soul and art and the laws of medicine, an uncertain science, by giving undue importance to the golden cage, its architecture, its grandeur, by envisioning a charade of educational reforms, thereby the medical students losing their passion and the attraction for medicine? Are we as medical educators causing attrition in the art of medicine, humanistic medicine, and passionate medicine and devitalizing the attractions of medicine within the internal culture and social milieu of medical schools today? Could the lack of passion in medical trainees be partly attributed to the poor selection process or inadequate selection tools that are not able to weed out medical entrants akin to “a square peg in a round hole”? This article will attempt to seek answers to my reflective and provocative thoughts and questions posed.
During my work abroad, I have very often met young brilliant graduates and doctors who are plagued by the questions “Do I really want to be in medicine? and Is medicine something I really want to do?” In other words, they introspect by asking two questions, i.e., “Am I truly doing what I'm passionate about in life; do I love my work; do I have a passion for medicine?” “Do we still find great satisfaction in taking care of people?” “Do we have the passion for taking care of people?” There are many, doctors, nurses, and medical students who are truly dedicated to their art; however, there are doctors who got into medicine not because they wanted to; some of them just didn't know what else they wanted to do; some of them wanted the money; others in the middle who are still going through the motions, still unsure of whether medicine is really right for them. Why has this happened? I wonder whether our clinical art of teaching, clinical examinations, and diagnostic approaches failed to create a passion toward the art and science of medicine. Clinical medicine should be an educational adventure, which is self-motivated by noncognitive personality attributes and a disciplined patient-centered process of learning. There should be a patient-focused approach with problem-oriented selective reading, not an examination-centered learning, combined with personal motivation and self-discipline, to go beyond the traditional classroom approach. Traditionally, the training of physicians involves both didactic and bedside teaching. The importance of bedside teaching and the art of doctoring have declined over the past few decades in many affluent countries. I reiterate that clinical bedside teaching does emphasize the interconnectivity among teacher, student, and patient; allows the teacher to role model the humanistic aspects of patient care and interpersonal skills (doctor–patient relationship). However, in the current modern era of medical world and medical school training, the emphasis is on organ-based, technocratic, reductionist mechano-materialistic, pathogenesis-centered, and disease-centered model approach rather than a humanistic, patient-centered, integrated approach of systems medicine, complementary and alternative medicine, and “relationship-centered medicine”. The art of doctoring does not mean abandoning the technologic marvels of modern science but rather incorporating them into a sensitive, humane, compassionate, and empathic care holistic approach. In medical schools, training no longer nurtures passion for compassionate medicine and it also does not create a learning environment to provide an opportunity for medical students to explore relationship-centered aspects of clinical practice. This unfortunately has resulted in physician empathy gap with an alarming void of compassion, humanism, and altruism in medical care.
The art and science of medicine gives the opportunity to serve patients, and thus the practice of medicine will be the most gratifying and fulfilling of all professions; this passion will materialize only for those graduates/physicians who immerse themselves in the profession. The professionalism I experienced during my formative medical school era seemed to have slipped into history. The then graduates were altruistic and deeply rooted in humanistic medicine. They enjoyed the struggle and delight of learning; were passionate about eliciting the art of history taking; had the pleasure of reading problem-oriented medicine in the wards, at the bedside, the excitement of opening the mind, the ability to ask questions, searching answers to their intellectual curiosity about patient illness, interacting with colleagues about medical problems in their leisure time, in the cafeteria; trying to solve puzzling medical scenarios; and spending quality time in library to keep their minds sharp enough to new knowledge. They possessed the zest for medical practice, the desire for intellectual stimulation, and the zeal to finding solutions to complex medical problems. They were medicos who derived enjoyment and personal satisfaction through intellectual advancement and self-motivated service to patients. Do I still see this breed of doctors or have they become extinct today? How can we preserve the altruism and passion for our modern medical profession? The answer will lie in the need to introduce medical humanism course in the medical curriculum, re-modeling the pedagogical strategies of teaching the art and science of medicine, as well as revamping the selection process of medical candidates by lending credence to the assessment of non-cognitive traits and personality attributes. This will unite humanism and medicine in tomorrow's doctors.
”The student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end” which emphasizes upon history taking, the first clinical skill learned at medical school that undoubtedly underpins all clinical diagnoses. Despite the current rapidly increasing trend for hi-technology medicine, we as “medical educators” should realize that the major impetus for indoctrinating the art and science of clinical diagnosis for “tomorrow's developing physicians” must be firmly grounded in properly gathered history and meticulously executed physical examination. Modern doctors are oriented toward technology-driven diagnosis, as they are either ignorant of these details or unwilling to invest time in history taking. Lord Platt of University College of London in 1949 had emphasized that history taking forms a fundamental vital piece of the physician–patient encounter that it contributed to the diagnosis in 76%–82% of cases. In the words of Hippocrates, “For where there is love of man, there is also love of the art; many patients recover from perilous health simply through contentment with their physician, as the then physicians had the art to talk to patients, and listened, hearing to the patients and to their illness behavior.” A quote from a lung cancer patient at the Massachusetts General Hospital: “I have learned that medicine is not merely about performing tests or surgeries, or administering drugs. These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness.” I reiterate “a human being, not just an illness.” That forms the crux of the relationship between a patient and a physician.
Sir William Osler's greatest contribution to medicine was to insist that students learned from seeing and talking to patients and the establishment of the medical residency. Quoting Osler-ism; “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” He is also remembered for saying, “If you listen carefully to the patient they will tell you the diagnosis” which emphasizes the importance of taking a good history. This Oslerian dictum should be resurrected in today's bedside clinical skill development. Such art of history taking and skillful-targeted clinical examination would go a long way to foster humanism, professionalism, and would ignite the healing encounter and build doctor–patient relationship. Formulation of a diagnosis through the mastery of clinical skills and higher-order thinking in the Bloom's cognitive taxonomy is akin to the detective work of Sherlock Holmes at the clinical bedside. The mastery of clinical skills is central to the transformation of a medical student into a competent health professional fit for medical practice.
Nurturing Passion for the “science and the Art” of Clinical Medicine and Self-Directed Lifelong Learning
The education of the doctor which goes on after he has his degree is, after all, the most important part of his education.
–John Shaw Billings
The art of medicine cannot be inherited, nor can it be copied from books.
These quotes emphasize the attributes that need to be nurtured, i.e., lifelong learning, curiosity, discipline, diligence, determination, compassion, and a sense of service. Lifelong learning at the heart of “Preserving the Passion” with a patient-oriented study would be the ideal roadmap for a developing physician.
Nurturing medical passion is all about harnessing of curiosity, a concept of inquiry, a quest for knowledge, and the pursuit for an in-depth study when we see a patient suffering from an illness. We need to develop a scientific humanistic temperament to study the phenomena of diseases. “Love, Medicine and Miracles” by Dr. Bernie Siegel reflects medical humanism and holistic medicine. Humanism is a system of beliefs concerned with the needs of people. Patients have clinical care needs as well as interpersonal care needs. Humanism in medicine aims to promote interpersonal care of patients. It is sad to note that the culture of medical schools today, a cradle for nurturing and fostering professionalism and humanism, is far from ideal. Humanism and professionalism, narrative medicine, cinemeducation, and empathy training are never taught or even attempted to be taught in a medical curriculum. In Indian medical schools, we need role model teachers, master clinicians, and educators in the reincarnation of the Oslerian spirit. Such leaders and torchbearers will have the vision to introduce innovative curriculum strategies to revamp medical education and rekindle the passion and the attractions of medicine in medical students. This would be feasible by cracking the hidden curriculum to indoctrinate tomorrow's physicians in the “art of doctoring” and to integrate their “logico-scientific” medical knowledge and clinical competencies with proficiency in humanities. I would reiterate that medicine is a plurality of science and humanitarian principles. Narrative-based medicine would indeed serve as a model for the development of self-awareness, altruism, compassion, empathy, professionalism, and physician–society public trustworthiness for an effective health-care enterprise. Through the innovative tools of narrative medicine and cinemeducation, the passion for humanistic medicine could be rekindled by evoking powerful learning experiences through archetypal experiences and the collective unconsciousness on the multifaceted dynamics of the doctor–patient relationship and patient-centered humanistic approach.
In my opinion, to preserve and rekindle the passion for learning the “art and science” of medicine among medical students, one needs to have curricular reforms that would facilitate creative learning resulting from the vertical integration of basic sciences knowledge and clinical disciplines into a cohesive whole. Due to the fragmented nonintegrated learning experience, there would be attrition in the interest and passion for clinical medicine which would lead to the lack of clinical skill acquisition, hyposkillia, and excessive reliance on overenthusiastic investigations as a surrogate to effective clinical bedside decision-making skills and diagnostic formulation. Here, medical trainees become servants of technology rather than its master, transforming the “heart, art, and soul” of clinical medicine to “hi-tech, no touch” medicine that is devoid of a healing encounter. As a result, the medical student frequently is not able to develop clinical reasoning skills, critical thinking, inductive and analytical reasoning to problem formulation, hypothesis generation, and inquiry strategy which leads to the lack of competence in a focused medical bedside examination and inability to apply their knowledge of basic sciences to clinical situations. This hinders the process of logico-deductive diagnostic formulation that leads to negative emotional experiences such as anxiety, dislike, and eventual disinterest in the clinical bedside medicine. Due to this nonintegrated, nonblended, and fragmented learning experience and the lack of applied knowledge in basic sciences and clinical medicine, the students perceive bedside medicine complex, and they develop a reluctance to approach clinical cases, thus losing passion in the art and science of clinical medicine. The development of hi-tech medicine, precision medicine, and telemedicine, undoubtedly has revolutionized modern 21st healthcare, but to my mind, I sadly witness the reduced interaction in the physician (healer)-patient bond, the decrement in this special relationship of mutual understanding and respect, that indeed leads to a loss of therapeutic empathy. This humanistic angle of hi-tech healthcare will be difficult to comprehend for those who themselves have not experienced what is it like to be a patient. This message has been well reflected in the classic portrayal of a doctor's (Dr. Jack McKee) transformation resulting from his own experience of an illness in the movie 'The Doctor'. As a part of cinemeducation, I underscore the absolute utility of this film extensively when teaching medical students and doctors at all stages of their careers.I would reiterate that the dehumanization of modern medicine by hi-technology would inevitably deteriorate certain vital essence of quality of healthcare and most importantly the patient-physician relationship and therapeutic encounter. Thus the modern era of this technology-driven surrogacy has led to a medicine that is not compassionate, and it has lost that special trust that once bonded the physician–patient relationship. Healing is replaced by treatment, and the art of listening is substituted by technological advances. This had led to dehumanization of a moral enterprise of health care, and the medical student trained in this milieu of “hi-tech medicine” would longer have the resources to harness a fascination and attraction for humanistic, compassionate, hi-touch medicine.
I underscore that the science and art of medicine should be based on a thoroughly constructed medical history, coupled with diligent physical examination, critical assessment, and a good clinical reasoning power, the so-called “méthod anatomo-clinique” of Charcot. Apart from the clinical diagnostic formulation, this professional encounter of “listening” (”listening to” and “listening with” the patient) does rehumanize “high-tech, no touch” modern medicine to its Oslerian roots. In order to rekindle and restore the passion for clinical bedside medicine, I would emphasize that the significance of clinical methods should always be preached, practiced, and should never lose its priority. Quoting Sir William Osler, “Medicine is learned by the bedside and not in the class room. Let not your conception of manifestations of disease come from work heard in the lecture room or read from the book: See and then research, compare and control. But see first.” Innovative teaching–learning methodologies to develop critical thinking on the higher levels of Bloom's cognitive taxonomy, creative and reflective thinking, problem-solving and decision-making, clinical judgment, skill development, self-regulated and self-directed learning, appreciative inquiry and learning styles, problem- and case-related learning, reflective learning and practice, experiential learning, and transformative learning are pivotal. There is absolutely an urgent need for early introduction of training clinical skills in the curriculum organized in a cascade of logical sequences at the very beginning of medical study, ensuring implementation of a student-centric competency-based education, and training by reinforcing the Socratic teaching method and collaborative learning so as to produce a final product of a competent physician with all prerequisite skills mastered. Such approaches will foster passion and attraction toward clinical medicine.
In the current era of technocratic medicine, clinical reasoning is a fundamental skill which should be taught in medical school that is quintessential to the practice of medicine. Clinical skills' training in undergraduate medical students is arguably the weakest point in medical schools' curriculum. Devising appropriate instructional approaches for teaching clinical reasoning is a daunting task, even when teachers are clinical reasoning experts themselves. Problems with clinical reasoning often occur because of inadequate knowledge of the disease, failure to activate prior knowledge, flaws in data gathering, and improper approaches to information processing. Hence undergraduate educational and curricular reforms must be centered on the various phases of clinical skill training. These include assessment of competence and proficiency through structured performance evaluation/workplace-based assessments (WBA-OSCE, OSPE, OSLER, Mini-CEX, DOPS, etc.)., Such paradigm shifts in teaching clinical medicine will indeed provide not only concrete evidence of clinical competence, but also drive medical students' learning. Clinical reasoning skills are not usually explicitly taught to learners, yet are fundamental to medical education and thus are a major challenge for medical educators. Teaching clinical reasoning should be central to medical teaching–learning process (through a clinical reasoning curriculum) rather than a passive by-product of clinical experience. Yet another novel method of enhancing clinical reasoning skills and in understanding and analyzing illness scripts in medical students is through narrative medicine and cinemeducation., These approaches will also be instrumental in developing empathy, professionalism, and communication skills resurrecting the “humane touch” not only with patients but also with each other and ourselves. Such clinical reasoning curriculum will attract students to the “science and art of bedside medicine” by removing their “clinical bedside phobia” and nurture the passion for clinical medicine in the young generation of medical students.
Another interesting facet to nurturing passion in medicine is implementing a formal mentorship program and “role model” educators during medical students' training. Mentoring is an essential catalyst not only for a successful training and medical career, but also instrumental in imparting a positive experience for both personal and professional development. This personal process that combines role modeling, apprenticeship, and nurturing would be a “specific pathway” to facilitate student productivity in clinical research and personal growth and certainly provide a positive educational journey in understanding the “science and art” of medicine. The role model educators could pave the way to integrate the preclinical undergraduate medical curriculum to facilitate applications of basic sciences to clinical scenarios which would go a long way to improve performance with aspects of their clinical knowledge and augment their comfort levels with clinical examination and clerkship, thereby ameliorating “atrophy of clinical skills.” Mentorship certainly would have a positive motivational influence on learning and also on reducing the stress in basic sciences and allied clinical sciences-related learning tasks. The emotional and experiential learning imparted by “role model” teachers during the formative clinical years of medical students would indeed go a long way forward to nurture their passion and attraction for the art and science of medicine and would also influence their future career options in various medical subspecialties. In addition, I would say that implementation of novel and flexible pedagogical teaching–learning multidimensional strategies in the 21st-century undergraduate classroom prioritized on self-directed learning, critical thinking skills, and focused on student-centered, problem-based, and integrated learning would certainly be the way forward to effective and quality medical education. Brain-based learning strategies, instructional strategies, and other innovative multidimensional approaches (simulation-based medical education programs; technology-enhanced simulation training; and web-based virtual learning environment) will undoubtedly create a conducive and exciting environment to orchestrate and optimize the medical students' learning experiences for the 21st-century learners, thereby preserving the passion for clinical medicine. We need to implement “hybrid approaches” and “Connectivist, Cognitivist, and Constructivist Models” for enriching the teaching–learning process in medical students which would undoubtedly play a pivotal role in nurturing passion for the science of medicine. I am sure that these evidence-based novel pedagogical initiatives, centered in adult and active learning theories, that go beyond the conventional didactic basic sciences and medical teaching strategies, incorporation of student-centered active learning methods, and technology-enhanced learning, will unquestionably change the learning landscape, where the novice medical students would develop a fascination, passion, love for clinical skills' attainment, bedside clinics, and attraction for clinical medicine.
Tomorrow's Doctors: Rehumanizing “hi-Tech, No Touch” Modern Medicine
Since the profession of medicine is under siege because of its de-humanized encounter, there must be a quest for upholding the integrity of medical professionalism and safeguarding its obligations to the society. With a deep-seated conviction, I therefore reiterate that medical professionalism and the moral enterprise of health care must be linked to humanism which would guarantee the dual roles of a “medical professional” and “healer.”
How do we undertake this moral enterprise of rehumanizing our modern medicine? We need to revisit Sir William Osler's words of wisdom and medical humanism. Osler's medical humanism and bedside teaching can be captured by eloquent aphorisms such as: “It is much more important to know what sort of patient has a disease than what sort of disease a patient has.” The contribution to medical education of which he was proudest was his idea of clinical clerkship. He urged to cultivate a number of qualities: the art of equanimity, of detachment from personal feelings and distractions that could interfere with an issue at hand; the virtue of using a systematic method for organizing work; the quality of thoroughness and meticulousness in assessing symptoms, signs, data, and opinions; the grace of humility; and a reverence for responsibility. He believed that the two most important characteristics a teacher should possess were enthusiasm and passion for medicine and experiential knowledge, rather than a repository of theoretical knowledge.
For “tomorrow's doctors,” we need to introduce a mandatory curriculum to nurture and foster professionalism and humanism in medical schools. There is an absolute need to transform the clinical learning milieu and social environment of our medical schools to one that will be conducive to encourage “professional socialization” through hidden curriculum and informal curriculum. I strongly make an argument for developing and teaching empathy in clinical encounters and health care as the way forward to humanize and transform the “depersonalized” medical practice at the heart of 21st-century health care.
I sometimes do wonder if our current medical schools have certain inherent deficiencies and shortcomings in training. Much of the time, students training in medical schools have been found to actually impede a physician's ability to solve complex problems because they have been trained for the left brain-dominant, linear, step-wise, analytical, and evidence-based knowledge vertical thinking. This traditional thinking approach does not generate new ideas or discover innovative solutions to complex challenges since it does not ignite creativity, curiosity, inquisitiveness, and wonderment termed as the multidirectional creative, lateral, or horizontal thinking. Similarly, medical schools do contribute not only to humanism and empathy deficiency, but also a lack of philosophy of health, well-being, and relationship-centered whole-person care and healing outcomes in training the art of doctoring. In some studies in the West, a clinically significant reduction in empathy score during the 3rd year of medical school was found. What does contribute to the down regulation of empathy during medical school training? A significant reduction of empathy in medical school has been attributed to multiple and complex factors, both at individual dispositional and situational levels. The prime focus of current medical education underscores disease-centered approach, detachment and objective clinical neutrality, and places greater reliance on the technologic rather than humanistic aspects of medicine. Clinical hyposkillia, a lack of empathic role models, educational experiences with emphasis on controlled clinical trials, evidence-based medicine (EBM) for clinical decision-making, focus on research at the expense of teaching and learning, increased litigation and defensive medicine, and the market-driven health-care system are other reasons for the erosion of empathy during medical education. Medical school stress, learning environment without a corresponding stress on humanistic values, and the “drudgery” of mastering medicine (strenuous demands including time pressure, sleep loss, heavy workloads, high volume of material to learn and mentors who model detachment when dealing with patients, and increased student and resident numbers with shrinking resources) have overshadowed the importance of human interactions and empathy development during medical school training. Therefore, I would vehemently state that educational interventions should be put in place to effectively foster empathy in medical students. Realistic goals to overcome medical school stress must be inculcated into the medical curriculum such as to practice mindfulness meditation, self-reflection and emotion skills for self-care, and a healthy work–life balance. These experiential “mind–body” medicine techniques have been found to go a long way to help medical students and professionals to recognize, regulate, and behaviorally demonstrate altruism, empathy, and uphold humanistic and prosocial attitudes and behaviors during professional encounters. I firmly believe that “teaching of humanities, empathy, and professionalism” within the very fabric of medical curriculum, internal culture, and social milieu of medical schools, hospitals, and health-care systems would certainly bridge the schism between the “heart, soul, and art” of doctoring (”hi-touch” medicine) and the empirical science of EBM (”hi-tech” medicine). I am sure that these steps would pave the way forward to reinvigorate passion for medicine and rekindle the flame of attraction of the medical profession in medical trainees in medical schools.
Personality Traits and Selection Process for Humanistic Medicine
”Educating the mind without educating the heart is no education at all.”
What keeps your passion for practicing medicine alive? Is it the sense of purpose you feel when a patient thrives? Is it the fulfillment of helping others through global missions? The “wanting” to become a doctor (medical student) can be nurtured and developed, but is certainly dependent on certain personality traits, the integrity of uncompromising character and medical aptitude. “What's behind oneself persevering to be a doctor; what is behind a student's choice for becoming a doctor; and why doctors are leaving the medical profession” may be analyzed on personality traits. People who are self-centered, utilitarian, individualistic, nonaltruistic, less grounded to ethics; with less unconscious desire to help others; not possessing the mental attitude to derive satisfaction by being useful to others, highly competitive, more ambitious, those with higher extra-professional concerns, more materialistic, and those desiring quick/fast financial gains are less likely to be doctors and have a stable career planning. A recent research study described a novel questionnaire, Medical Situations Questionnaire, that assessed the interests and attractions of different aspects of medical practice in a varied range of medical scenarios and related them to demographic, academic, personality, and learning style measures in a large group of premedical students. Exploratory factor analysis of the Medical Situations Questionnaire found evidence for four factors (indispensability, helping others, respect, and science) that could account for much of the variance in the reasons that individuals differ in their motivations for medicine and in their interests in medicine as a career.
Is there a right sort of personality for pursuing medical profession with passion? Many medical schools believe that selection of candidates should be on grounds other than mere academic achievements. Vocational theories have implicated so many “conscious” and “unconscious” noncognitive attributes such as psychological, sociocultural, economic, personality, coherence factors (a measure of person's resistance to stress and their ability to manage stress), self-esteem, personal factors, and career motivation (intrinsic, extrinsic, and extra-professional concerns). Since the medical profession is stressful, students and young doctors who are more inclined toward arts and humanities, those with an ability to balance professional work with social life, and those who can handle ambiguity cope better with the aspects of medicine that the more scientifically oriented find difficult. Some of the most common reasons for dropping out of medical schools were because it was not for them, they found it boring, they did not like patients, the long working hours was not what they wanted to spend their time on, they did not like responsibility, or did not have the mental resilience to handle pressure.
Dr. Bernard Lown said: “Caring without science is well-intentioned kindness, but not medicine. On the other hand, science without caring empties medicine of healing and negates the great potential of an ancient profession. The two complement and are essential to the art of doctoring.” Therefore, medical schools need to ensure that only those medical applicants who are most likely to succeed are selected for medical training. Today, I would reiterate that there is an “iatrogenic crisis in caring” where not only the “art of doctoring” but also the “art of healing” is lost. In addition, there is also a “social disconnectedness,” a “detached concern, and heartlessness” in our clinical and professional encounters. Since the moral enterprise of medicine is a plurality of science and humanitarian principles, we need to reinvigorate or re-model training in medical schools for a more humane, compassionate, altruistic, and empathic care holistic approach. We need to bridge the schism between the “science” and “art” of the practice of medicine. For this, we need to have curricular reforms in medical schools to teach and develop the “art of doctoring” and “emotionally inclusive care” for tomorrow's physicians that will undoubtedly rekindle the passion and attraction for clinical medicine in medical students.
Since medicine at its center is a moral and ethical enterprise, medicine is a special kind of professional activity that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity (professionalism), compassion (humanism), and effacement of excessive self-interest (altruism). In this respect, I ask the quintessential question that “What is the role of aptitude tests, if any, have in the selection of medical students?” The answer to this question is unequivocally in the affirmative. There is a growing interest in determining whether factors other than cognitive ability and previous academic performance can influence academic success in medical school. We need selection tools and processes that would measure “aptitude” for medicine, and test knowledge and reasoning ability in science and humanities. It is prudent to evaluate noneducational scores and achievement using noncognitive attributes such as general mental ability, critical thinking, problem-solving, communication skills, empathy, psychological robustness, and integrity that are absolutely essential in the “art of doctoring” with compassion, altruism, relationship-centered holistic care, and empathy. I would unhesitatingly state that medical schools in India need to develop and evaluate selection methods that may be useful adjuncts in a holistic selection process that would produce doctors and medical workforce in the future with a passion for medicine, thus humanizing health-care services.
Although in India, medical schools have traditionally relied on academic criteria (NEET) as opposed to the international MCAT and GPA in admission procedures, there is currently a widespread agreement that medical students should be selected using not only academic scores (”book smarts”), but also nonacademic and noncognitive criteria, such as professional, communication, ethical reasoning, and interpersonal skills.,, Thus, isn't the NEET in India that aims to select the most highly academically and intellectually qualified students in the expectation that they will make the best doctors a wrong perception? Therefore, I would reiterate that the time has come for a radical change in India. Instead of placing emphasis to differentiate top ranks in knowledge-based cognitive scores (academic achievement) of medical applicants, the selection process should be better focused on identifying those potentially unsuitable candidates based on noncognitive and personality attributes to ensure that they do not gain entry. I believe that there should be a new system and selection process for cultivating or developing tomorrow's physicians. Candidates for medicine should possess excellent character traits or personality traits such as trust, benevolence, intellectual honesty, courage, compassion, and truthfulness.
Selection strategies should not only consider educational achievement, but also the aptitude for future study and desirable personal characteristics. It is quintessential to understand the reasons or motives for entering the career of medicine so as to enable them to pursue satisfying careers and remain passionate about clinical medicine. In this respect, medical schools should try to select those applicants with the greatest vocational inclination toward a medical career and assess applicants' ability to acquire clinical skills and assume the professional attitude appropriate for humanistic medical practice. I would vehemently state that aptitude tests (Undergraduate Medicine and Health Sciences Admission Test, Graduate Australian Medical Schools Admissions Test [GAMSAT], United Kingdom Clinical Aptitude Test [UKCAT]), personal interviews, multiple mini-interviews to assess nonacademic skills and attributes, and personality testing (Personal Qualities Assessment [PQA] Instrument) for desirable personal characteristics during the process of selecting students for medical school is quintessential. Therefore the admission criteria to medical schools should be reformed. Medical interview with Thematic Apperception Test and 16 Personality Factor Questionnaire would analyze the positive factors of the personalities of the candidates since future compassionate doctors could be nurtured from among those who already have this inherent potential.,, The Graduate Medical School Admissions Test (Australian GAMSAT) defines intellectual ability in terms of critical reasoning and problem-solving; examining a candidate's understanding of interpersonal issues and written communication. The UKCAT assesses quantitative reasoning, decision analysis, verbal reasoning, and abstract reasoning. The PQA test assesses verbal, numerical, and spatial reasoning by its mental agility test, contains a personality inventory, and has an ethical reasoning paper. These tests aim to assess beyond the sphere of intellectual ability and does predict the desirable noncognitive characteristics in potential medical students. These would indeed be predictive of their professional responsibilities and medical decision-making and the ultimate satisfaction in practicing the science of medicine and the art of doctoring that has significant implications for the quality of health care. The selection of medical students who are more likely to be satisfied with medicine as a career would most probably also lead to longer, passionate and well balanced work-life balance, better quality of care, and the promise of humanism and professionalism. However, this is a debatable area as we need to design and assess the various selection methods that would reliably and predictably work in the right direction (how to select and whom to select) in selecting medical students.
Hippocrates, the Father of Medicine, proposed that doctors should have natural skills, culture, disposition for studying, a strong background of clinical knowledge and skills, perseverance, enjoy work, and have the adequate time to spend for patients. Nevertheless, the selection of new medical students usually does not take into consideration these characteristics, but rather emphasizes cognitive aspects. The determinants for choosing a medical career must include personality; conscious factors such as the desire for helping people, preference for biological knowledge, and scientific curiosity; unconscious factors such as the capacity for reparation and sublimation; and socioeconomic factors. Exploration of personality traits using “sense of coherence scale,” a measure of a person's resistance to stress and their ability to manage stress; Personal Attributes Questionnaire; Rosenberg-Self-Esteem-scale; and Career Motivation Questionnaire has been linked to career planning, career motivation, and academic achievement. Intrinsic career motivation (i.e., enjoyment of and interest in professional activities), extrinsic career motivation (i.e., striving for promotion, income, and prestige), and extra-professional concerns (i.e., prioritizing family, work–life balance, convenient working hours, and job security) are all variables that determine career motivation.
Although it is widely accepted that becoming a “good” doctor requires personal qualities beyond intellectual ability, the various alternative selection methods alluded to earlier are often criticized for their perceived lack of reliability and validity. Further qualitative research into the various selection tools is absolutely necessary. Assessments of these personality and character traits as admission criteria would ensure selection of candidates who would be torchbearers of future compassionate and humanistic medicine. If medical educators are trained for a fundamental attitudinal change on the part of academic medicine, that would encourage a renaissance in the art of clinical medicine, skill training and competence, and bedside clinical diagnosis, which will ultimately nurture passion, fascination, and attraction for clinical medicine that lights the path for humanistic medicine in medical students of tomorrow and the future medical workforce.
Finally, I would in no uncertain terms reiterate that medical school curricula must encourage and foster passion and attraction for clinical and academic medicine and reinvigorate student goals and personal aspirations about patient–physician relationship, healing, physician emotions, prosocial qualities of humanism, empathy, altruism, and relationship-centered care, the interest in people and the role of love, fascination, and awe in medicine. Medical schools should teach and cultivate these prosocial attributes to medical students in their formative years. The intrinsic motive of “high satisfaction and interest in people” and “sensitivity to the pain or suffering of another” coupled with a deep desire to alleviate that suffering (compassionate therapeutic relationships) certainly resonates with the words of Dalai Lama “The more we care for the happiness of others, the greater our own sense of well-being becomes” which probably best summarizes the personal qualities and personality traits best suited to nurture passion and attractions for medicine. Medicine should be a mission, should be inspirational, unconditional interest in humanity, passion, and the inner drive for compassionate care unconditional positive regard, empathy, and genuineness for fellow human beings.
We need to rediscover the roots of our profession: the relationship between patient and physician, and within these relationships, we can find no greater satisfaction. Medicine is a professional journey that should be driven by passion to heal patients and medical humanism. To conclude, I would quite unwittingly and unhesitatingly state that medicine is still the best profession in the world. It is with this humbling thought that I would state that “The Laws of Medicine” is indeed a science of uncertainty and an art of probability, so medical students and doctors should not only learn and practice only the science of medicine, but also necessarily the “art of medicine” and the “art of doctoring” at the “heart of medicine” so that we become true healers of the body, mind, and spirit.
”Knowledge and wisdom, far from being one, Have oft-times no connection. Knowledge dwells In heads replete with thoughts of other men Wisdom in mind attentive to their own Knowledge is proud that he has learned so much Wisdom is humble that he knows no more.”
–Sir William Osler
An inquiring, analytical mind; an unquenchable thirst for new knowledge; and a heartfelt compassion for the ailing-these are prominent traits among the committed clinicians who have preserved the passion for medicine.
–Lois DeBakey, Ph.D
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