1. PHOTO: SHUTTERSTOCK/ZSOLT NYULASZI November 5, 2007 America Vol. 197 No. 14, Whole No. 4792
Can physicians be trained to care?
A Struggle for
the Soul of Medicine
– BY MYLES N. SHEEHAN –
A
T MOST MEDICAL SCHOOLS in the United States, students are given a
white coat during a ceremony in the first weeks after matriculation, and
they are told about the role they will play and their obligation to serve
others. These days medical training, both at the undergraduate and post-
graduate (residency training) levels, is explicitly linked to attaining spe-
cific competencies. The decision to require demonstration of competencies reflects a
perception that American doctors might be well trained in science and technology but
lack some other crucial skills one would want from a doctor. It is an effort to remedy the
worst deficiencies.
The Accreditation Council for Graduate Medical Education, the governing organi-
zation for postgraduate physician training, requires the mastery of six particular com-
MYLES N. SHEEHAN, S.J., M.D. , is senior associate dean and the Ralph P. Leischner
Professor of Medical Education at Loyola University Stritch School of Medicine in Chicago,
Ill. This article is based on a lecture presented at Trinity College Medical School,
Dublin, Ireland, in May 2007.
November 5, 2007 America 9

2. petencies before one can be recognized as a specialist in a
particular discipline. These are medical knowledge, com-
munication skills, practice-based learning, patient care, pro-
fessionalism and systems of health care. That last term
refers to the ability of a physician in training to understand
the differing environments in which patients are cared for,
to work with the health care system to ensure continuity of
care and to cooperate with efforts that ensure patient safety
and standards of quality and proficiency.
Increasingly, medical education combines knowledge of
basic science and skills in caring for patients with explicit
curricula in communication, simulation and team training.
It also develops in practitioners a habit of reflection that
leads them to review individual cases and make comparisons
with the evidence in the literature and in conformity with
national standards.
The problem is that this broader curriculum is being
developed at a time when faculty members of medical
schools already feel pressed by productivity demands that
limit the time clinicians can spend with students and that
force researchers to juggle classroom teaching and writing
applications for the grants necessary for ongoing funding.
What lies beneath the current discussion about profes-
sionalism in medicine is that, despite increasing technical
and scientific opportunities, the purpose of medical educa-
tion is still to train physicians who understand the values
they profess, the meaning of what they do and the impor-
tance of their relationships with patients, other caregivers
and society at large. The struggle for medicine’s soul is
being waged on the field of medical education.
Training in Virtue
Medicine is a humane discipline that combines art and sci-
ence, but it depends above all on practitioners who are pas-
sionate about caring for patients. To use terminology from
scholastic philosophy, medical education is training in
virtue, with virtue understood as a human potential brought
to action by education, training, reflection, consideration of
role models and experience. Medical education requires
growth in both intellectual and moral virtues. The intellec-
tual virtues of art and prudence aim at finding the reality of
the clinical encounter. The moral virtues of temperance,
fortitude and justice aim at right action in the best interests
of one’s patient.
The struggle about how best to form physicians is not
new, but a variety of new challenges makes it especially
pressing. The possibilities in medicine—of treating individ-
uals, of providing a variety of technological solutions for a
particular problem (including the promise of molecular
genetics)—are dazzling. Yet physicians also struggle with
how to live well as persons, how to care for the poor and
how to befriend those who seek their assistance. These days
10 America November 5, 2007

3. there is more to distract us, like worries about how to main-
tain a reasonable income, meet productivity demands and
deal with regulatory and bureaucratic requirements.
Education that ensures respect for patients while not dimin-
ishing the humanity of those in training remains a daunting
challenge.
Focusing on the Physician in Training
When developing a curriculum, my aim is to train students
who are ready for the demands of patient-centered
medicine. Such students can deliver personalized care while
using knowledge and skills that are highly technical. They
can understand how a person’s individual genetic makeup
will allow appropriate therapeutic choices, tailor treatment
for cancer and other illnesses, and make prudent decisions
about ways to limit risk. But personalized care and patient-
centered medicine also mean retaining and deepening an
older tradition: the ability to communicate with those in our
care and to work with them in making decisions about their
health care that serve their best interests.
It is hard to see how students can grow in their ability to
provide patient-centered care if medical educators do not
grow in student-centered education. Behind this assertion
are some simple considerations. Medical school curricula
are too often dominated by a feudal mind-set; individual
departments hold sway over students as they move from dis-
cipline to discipline. Increasingly, however (accelerated in
the United States by accreditation and regulatory require-
ments calling for demonstrated proficiency in core compe-
tencies), a curriculum is being developed that looks at the
objectives necessary to prepare those ready for the next
stage of training. Individual disciplines are crucial but in an
instrumental manner; each works to provide training that
imparts the necessary knowledge, skills and attitudes to
developing the ideal graduate.
My own training has given me a high level of knowledge
in biochemistry, physiology, anatomy, microbiology and
pathology, plus a more practical set of skills and knowledge
in the clinical disciplines. But it did not prepare me well to
take care of people with a cold or individuals facing a life-
limiting illness, or to talk to a person who has just received
a bad diagnosis or to work in the best way with nurses and
social workers. With a bit of exaggeration, I suggest that my
medical school and residency training emphasized personal
mastery, but did not address well how to deal with change
or conflicting evidence or how to work as a team member
or to act like a human being with patients. I could detail bio-
chemical pathways about carbohydrate metabolism (and am
still fairly good at that), but I had much difficulty telling a
poor obese patient what to do with diet, exercise and medi-
cation in the face of Type II diabetes mellitus.
At Loyola University we emphasize an education com-
November 5, 2007 America 11

4. mitted to ethics and service and to a translational knowledge find an answer, rather than passively receive it.
of basic science as well as to the development of robust clin- It is difficult for some medical school faculty people to
ical skills. We seek to provide very strong student services recognize that the old methods of learning are not effective
(part of the Jesuit educational tradition of cura personalis) for this generation, which was brought up on computers,
while delivering a value-laden education that gives students accustomed to streaming video and hooked up to an iPod.
extensive exposure to care of the poor, international service Given the glut of information, teachers must acknowledge
trips and rigorous basic science training. In addition, our that some of what they cherish in a particular discipline may
clinical rotations are very demanding, with many overnights not be very relevant in contemporary practice. As a new
“on call” and an expectation that the student will become graduate in 1981, I could have told you much about the life
increasingly independent in responsibility, while under cycle of the pinworm, but I look back on that now with
appropriate supervision. some horror, recalling that more than 20 hours in my cur-
If the medium is the message, far too much of medical riculum were devoted to lectures on parasites, but only an
education is passive in format: lengthy lectures impart much hour or two on end-of-life topics. As a geriatric specialist
information but can leave a learner bewildered about what today, I realize I was not well prepared. Pinworm rarely
is essential. Focusing on objectives helps, but it is not afflicts my centenarians. My students and I can search the
enough. For a format that relies too much on lectures not Web to learn about parasites when we need to. The faculty
only ignores the needs of active learning but also fails to rec- does have essentials to impart, but students and faculty alike
ognize the experience students bring to their education. must still learn much more once the core topics are mas-
Small-group learning focused on cases or problems may tered.
improve on this, but it is no panacea. For this to succeed,
faculty members must be willing to facilitate, not control, Focusing on the Patient
learning. Most threatening in my experience were the times Although not every physician will work directly with
I had to admit I was not sure of an answer when the students patients, the goal of medical education is to provide the best
moved a discussion beyond my intellectual safety zone. care possible. Part of the rationale behind competency-
Modeling how to address such questions helps students get based objectives and standards for training is to move
used to the need to work together and figure out how to beyond knowledge-based examinations. That emphasis may
November 5, 2007 America 13

5. Itprovide patient-centered carecanmedical educators do
to
is hard to see how students
if
grow in their ability
not grow in student-centered education.
be new, but medicine has always recognized the exemplary who are both skilled and caring. Second, put the best and
performance of physicians who care for patients with a deep brightest physicians who care about students and physicians
wealth of basic and clinical knowledge. Such physicians are in training into positions of authority and leadership. Third,
also attuned to each patient’s individual characteristics and recognize the importance of role models and ensure that the
specific needs as human beings. They show a willingness to doctors who represent the ideals of what a doctor can be
try to heal a patient even when a cure or technological rem- provide most of the clinical teaching.
edy is not always possible. Developing patient-centered care Formation in technical knowledge, practical knowledge
requires practitioners who are ready to grow as humans and and wisdom does not mean training nice people who are
as clinicians during their training and afterward. It also ignorant but pleasant; rather it aims toward growth in
demands that they become increasingly sophisticated in virtue, which is hard work and inevitably entails some fail-
mobilizing the resources of a particular health care system. ure and frustration. This model is not typical. In the United
A physician must use the talents and skills of other health States, assigning responsibility for running a training pro-
care professionals in a collaborative manner, while attend- gram has often been a way of providing a salary to some
ing to best practices, prevention, quality and safety. bright young academic physician while he or she develops a
How does one promote an education by which students research agenda and searches for outside funding. The
and novice physicians can grow in technical skills, practical training program provided relatively cheap labor (the physi-
knowledge and some degree of wisdom? Let me suggest cians in training), with minimal supervision. Much learning
three steps. First, take medical education seriously as a for- still took place, but what counted was that the young physi-
mation process whose goal is to develop men and women cians got the work done, did not complain and passed their
14 America November 5, 2007

6. specialty exams. A student could be thoroughly objection-
able in matters great and small but still advance.
Training doctors in person-centered care works only if
the educators doing the formation understand the process
of giving such care and also care deeply about the doctors
they are training. Such learner-centered education requires
individual assessment, assistance in areas where growth is
required and encouragement of students’ questions. It
takes discipline to ensure that the education is properly bal-
anced: ongoing learning in science, attention to skill train-
ing, team development and personal growth. It takes edu-
cators willing to work with trainees who may be very bright
but manifest little interest in developing communication
skills, behaving professionally or learning other behaviors
that may once have been considered pleasant but merely
optional.
Ultimately, the future of medical education depends on
medical school faculty and administrators who care about
education and patient care. In a very complex environment,
that means devoting time and resources to students and
physicians in training. It also requires selecting, paying and
promoting faculty members who excel in both their partic-
ular discipline and devotion to their students. A
From America's archives: Myles N. Sheehan, S.J., M.D.,
on “Dying Well” (7/29/00), at www.americamagazine.org
November 5, 2007 America 17