“Study supports move to make professionalism a requirement for graduating from medical school” (EurekAlert) The study examined 235 graduates since 1970 of three medical schools who later underwent disciplinary action by their state medical boards in forty states; they were compared with matched gradautes from the same medical school classes who had not been sanctioned. Unprofessionalism in medical school was much more highly correlated with later disciplinary action than measures of academic performance. The strongest correlate of later disciplinary action was irresponsibility in attendance or patient care as a medical student. I don’t actually find this to be a surprising result. The cultural context of the study is more interesting.

I have noted through my years in the profession that accusing a physicial of “unprofessional” conduct is virtually the most stinging rebuke you can proffer (and, in the interest of full disclosure, I can say that I have been on the receiving end of it from time to time…). Healthcare professionals are conditioned to use that term for its button-pushing power as an insult with a power I would venture to say is unparallelled in any other profession. I think this has something to do with the longstanding notion that being a physician was a cultural signifier of a certain kind of character. Unfortunately, I think this is an outmoded meme and that there is nothing particularly more upstanding about the character of physicians these days than representatives of other professions anymore. Unscrupulousness, money-grubbing, laxity, predatory behavior and profiteering are as incident in the medical field as anywhere else, albeit much more disturbing when you are literally putting your life in someone’s hands. I think this is in large part the basis for the public contemptuousness toward doctors as a profession these days.

In this sense, the researchers’ interest is an anachronism. Cynical me, while I agree that reforming medical school curriculum to stress professionalism would be a worthy goal, I am skeptical about the suggestion carrying any weight or attracting much of a constituency among medical educators and medical school policy-makers in 21st century medical education. It is even less likely that some standard of professionalism — or character — might become a medical school graduation criterion. And, even if the assessment of professionalism were a goal to which there was an interest in aspiring, it would be especially worrisome if, as the article suggests, some attempt was made to operationalize it — ‘that standardized methods should be implemented for both assessing the personal qualities of medical school applicants and predicting their performance.’

I am not sure if the researchers realize how profoundly their results represent an impeachment of one of the current core methods of assessing character and professionalism (at both the levels of getting into medical school and of looking for one’s first job in medicine (“residency”) after graduating from medical school) — the letter of recommendation. As someone who has served on medical school and residency admission committees and been involved in the hiring of physicians, I have found the consideration of reference letters to be a vacuous exercise, both because the substance of what is written is so stereotyped, platitudinous and vague, and because the candidate exercises so much control over the sources of their letters. Even ambivalent letters which attempt to signal concerns about candidates do so obscured behind euphemism and buzzword that is difficult to decode unambiguously. (Here is a tongue-in-cheek but sadly all-too-true, guide to decoding letters of reference, although not specific to medical aspirants.)

Medical reference writers employ a sort of gentlemen’s code akin to the deference which European aristocrats were constrained to show to one another in public merely because of their membership in the noble class. Sniping, backbiting and criticism occurred only behind the scenes and only in a manner that could be protected by plausible deniability. For all the pride that physicians supposedly take in their professionalism, their nobility,, it has not extended to the responsible exercise of the art of recommendation. Perhaps there ought to be a module on writing references in the medical school curriculum?