 It's an honor for me to introduce my friend and colleague, Catherine Montgomery, the Julia and David E. Line Professor of Medicine, Humanities and Bioethics, and Professor of Medicine at Northwestern University's Feinberg School of Medicine, where she directs graduate studies in the medical ethics and humanities program. Catherine Montgomery is a true pioneer in the movement to integrate the humanities and social sciences into the medical curriculum. While an English professor at Morehouse College, she joined that institution's medical education project, as chair of the task force for interfacing the social sciences and humanities with the medical curriculum. Before moving to Northwestern in 1988, she was director of the division of the medical humanities at the University of Rochester School of Medicine. In the 1980s, she served on a working group of the Association of the American Medical Colleges, AAMC, study of the general professional education of physicians, and on the Kaiser AAMC advisory committee to the new pathways at Harvard Medical School. At each of her own institutions, she has been part of a thoroughgoing curriculum reform, three in all. With grants from the National Science Foundation, the National Endowment for the Humanities, and the American Council of Learned Societies, Catherine Montgomery has created an inspiring body of work concerning literature and medicine, the epistemology of medicine, and the use of literature in medical education that is exemplary for its high level of scholarship. She belongs to the Chicago Narrative Reading Group and is or has been on the editorial boards of Literature and Medicine, the American Journal of Bioethics, the Medical Humanities Review, and the Journal for the Evaluation of Clinical Practice. She was the 2001-2002 president of the American Society for Bioethics and Humanities, and she's been a fellow at the Hastings Center for Bioethics since 2004, and has been on the Fellows Council since 2009. She's the author of several important books, including Doctor Stories, the Narrative Structure of Medical Knowledge, Princeton 1991, and How Doctors Think, Clinical Judgment and the Practice of Medicine, Oxford 2006. Please join me in welcoming Catherine today for her talk titled, Medical Professionalism, etiquette or hepatitis? Thank you, thanks. It's a treat to be here. I've been hearing about all these activities, noon lunches, noon conferences for a long time. I left the clicker. Thank you. Though I'm not going to use it much. Professionalism is a vexed topic for me for several reasons. It's vague and sometimes threatening. I find it, it's vague for reasons that you've been exploring all of this academic year and threatening because it's often used to enforce a self-denying ethos for physicians, one that ultimately, I believe, endangers patients and certainly can narrow the life of a physician. In addition, it can substitute rules of behavior, protocol for the genuine understanding of medicine as a profession and for the process of acculturation in medical education as a substitute or better, a kind of placeholder for what's truly essential about being a physician. Professionalism reinforces the tendency to regard clinical medicine as a science. On the other hand though, professionalism does push back against the commodification of medicine and it has liberated many a physician educator from the fear that they might need a degree in philosophy or at least a fellowship in bioethics in order to guide their students in their quest to become physicians. Without resorting to T groups, professionalism has fostered a trend in medical schools for reflective writing, for small group discussions and other means of promoting self-awareness during medical school. So with those reservations, I'll begin with definitions. We know what etiquette is. It's a code... Oops, did I lean on it? We know what etiquette is. It's a code of proper behavior in a community which is not a bad thing. In fact, as a southerner, I believe devoutly in etiquette. As a set of behavioral rules, it glues and resolves and soothes human interaction. And more broadly, it establishes expectations that foster and reward civility. And also as a southerner, I know that morality can be legislated. That rules can make room for genuine civic connection that might have been out of the question before that legislation was enacted. I think of the testimony of Ivan Allen, Mayor of Atlanta during the Civil Rights Movement 50 years ago, who asked the U.S. Congress to please pass the Public Accommodations Act so that the white citizens of Atlanta would be free to include African-Americans in stores and restaurants without the censure and... Oops, I'm going to move this. Without the censure and the threat of harm from segregationists, I promise not to step on it and to ultimately get to peer-aboard you. So, in any case, I don't want you to understand that I'm denigrating etiquette, either traditional or legislative. We should go on encouraging medical students to sit down to talk to patients, to make eye contact, to introduce themselves, to use patients' last names, to listen to the patient's story even a little longer than the 28 seconds that's been documented as the average. And that's an improvement when my colleague Mary Ann Padgett did the study 25 years ago. It was 18 seconds. So, gosh, it's almost close to doubling. All those things that I just listed are good professional behavior with sound clinically beneficial reasons to support them. But etiquette or prescribed conduct is not enough. Our concept of professionalism should be more complex. More complex than rules of behavior, however admirable they may be, it should take into account the interaction of culture and psychology in the individual physician as he or she goes about the work of taking care of patients. This is a much more nuanced matter than mere rules. And this is where Habitus comes in. And I get to... By Habitus, I don't mean physical build, which is the way medicine and psychology use the word, but an ingrained predisposition expressed in the body, in behavior. Unless we think of it as a mere physical habit, sort of a tick or something you'd like to change so you could stop eating Oreos after dinner. Pierboard U and The Logic of Practice describes it as an ingrained orientation that enforces what can and cannot be thought in the culture, which is pretty powerful way beyond, you know, our president sneaks off for a cigarette. Rumor has it from time to time. Before Broadview, there was John Dewey, kind of a patron saint around here. I had a child who went to the lab school. I know about John Dewey. He should be a patron saint in medical education more generally. There, there he is. In his exploration of character and morality in human nature and conduct, he describes habit as their point of confluence. The social environment acts through native impulses. I want you to think about native impulses, what those might be. And speech and moral habitude manifest themselves. The question writ large is one that also engages literary theorists and historiographers and really all of us as we think about the course of our lives. Is behavior the result of our individual choice or is it culturally predetermined? Remember deciding to come to the University of Chicago? Thinking you might be determining your whole life by, through that choice, that the life partner you choose might be the result of that decision to say nothing of the direction of your life's work. One choice, choice creates determination. Looked at closely as it must be the relationship between individual agency and cultural determinism complicates itself. Beyond the degree to which individual choice is shaped or compelled or restricted by culture, there's an even more interesting question. How is cultural predetermination shaped by individual choices? One's own over a lifetime or those of one's predecessors? How do the two interact? Pierre Bourdieu's account of habitus furthers Dewey's argument. In fact, if you're an American chauvinist, you read Dewey and say, he got it all from here. He furthers Dewey's argument when he moves each half of the interaction of culture on the one hand and psychology into the territory of the other. Habitus is both inherited and absorbed, both social and psychological. It's the individual's cultural predisposition to perceive or know or act. This is what medical students acquire through the long years of education. It's both the overt and covert curriculum at work on who they are, what they know and do, what they believe and see, what they believe and are able to see. The physician's cultural predisposition to perceive or know or act takes shape as clinical judgment that Genese Qua physicianhood. And this is the essence, in my view, of medical professionalism. For clinical medicine is not a science, but a practice. It uses science, of course, but it is as it always has been, the care of sick people. And if it's to be well-grounded enough to be taught and maintained as a profession rather than a business, clinical medicine needs a clearer sense of its own identity, of its characteristic rationality. Even in an era of evidence-based medicine, good clinical practice relies upon judgment rather than being itself a science. Or, if you're going to insist on its being a science, and I know where I'm speaking, it's that thing that Aristotle and the metaphysics said is an impossibility. It's a science of individuals. For how can you establish general principles, much less covering laws, universals, for the particular and variable phenomena of illness? You need a law for almost every patient. And in fact, you know, clinical medicine has one. Nothing is 100% certain in medicine, except that nothing is 100% certain. That's a good law. And worse, especially for people who are sick and their families, how can anything be known with absolute certainty about an individual patient? In the Nicomachean Ethics, Aristotle distinguished among five different kinds of knowing. Here's what he has to say about practice. He distinguishes among five different ways of knowing. He calls them intellectual virtues. And I've left out Sophia, which is not the system and news, which gets translated as intuition, but it's not the kind of system one thinking that we're used to thinking of intuition now that we're allowed to talk about it. When I first got interested in all this stuff, you couldn't utter the word intuition in a medical school. Or really, if you'll forgive me, in the company of men. It just belonged to girls. It was girl stuff. But if you've read Daniel Kahneman's recent book, or any of the essays on system one and system two thinking, you've encountered a psychological explanation of how that ingrained knowingness that Malcolm Gladwell writes about in Blink interacts with and affects, there's a mutual effect actually. The sort of logical, rational thing that we think of as thinking. Aristotle's news is more like instinct and I've left it out here. Episteme is the intellectual virtue associated with science. He says it's knowing about fixed things about rocks and stars and atoms. Techne is know-how, the intellectual virtue that characterizes craft. Surgeons talk about their fingers thinking. Cooking, suturing, intubation, surgery. And sort of in between, I mean he does discuss them in a, discuss phronesis in a medial position. In between, there's phronesis. Practical reason. Spiritual virtue that's associated with deciding what to do in situations that might change, that might be changing as you decide or that are different from what you saw when you saw what you might describe as the same thing last week. And Aristotle talks about medicine or health and navigation and ethics. This is after all the Nicomachean ethics that he's describing the kind of moral reasoning that people need to cultivate. Phronesis gets translated as prudence, a translation I'm not fond of. I mentioned my southern background. Prudence has always seemed to me a kind of stingy word. I'd rather use the Greek and David Leach who was head of the ACGME went around talking about phronesis for his whole tenure in office and I was just delighted. So, don't translate it. You're at the University of Chicago. Call it phronesis. If you must translate it, I think street smarts might be a good translation or simply intelligence. It tends to be what we mean when we say someone is smart. They know how to negotiate the situations of life. In any case, it's judgment. It's a flexible, interpretive capacity that enables moral reasoners as well as the healthcare providers and navigators whom Aristotle cites as analogs. This won't do. It enables them to take to decide the best actions to take when knowledge depends on circumstances. It's not that the certainty of fixed things that's available in physics and some areas of biology is undesirable or irrelevant in medicine or in moral life, but that medicine and ethics and navigation differ from the sciences because that kind of knowledge is simply not available. Scientific reasoning has vision and replicability, right answers, and that can be a goal for from Nises. If you're sailing a sailboat in a tough wind you want the right answer and if you do it once you want to be able to do it again. It's fine as a goal, but practical reasoning enables the reasoner to distinguish in a given situation the better choice from the worse. It goes for workable answers right now. The first is law-like and generalizable. The second is inescapably particular and reinterpretable. For this reason medical education which is an education in practical rationality is inevitably a moral education even without adding any ethics classes. Practical reasoners must learn what to do, how to behave in situations that are inherently uncertain and while there's surely wrong answers there's usually a range of acceptable ones. Medical education has the task of taking young people who have studied science all their lives and who have grown up thinking that medicine is a science because they find it all around themselves in the popular culture and turning them into flexible practical narrative reasoners who can look at an infant with flu-ish symptoms and see kidney reflux disease or distinguish bronchopulmonary aspergillosis from other lung ailments. Medicine then is rational and science-using but that's very different from being itself a science. Practical reasoners people who possess phronesis grasp of particulars and the situational knowing enables them to choose the right thing to do. Sometimes this seems automatic and in a bit like driving a car or riding a bicycle though those fall more into the technique but still automatic. Decisions seem actually Sherlock Holmes is the perfect analog for that his explanations to Watson. Watson says how in the world did you know that? And Sherlock Holmes says perfectly easy perfectly sensible. The inability of clinical experts to identify the general rules that guide them prompted Edward Feigenbaum an originator of artificial intelligence who was studying clinical knowing to say at this point knowledge threatens to become 10,000 special cases. As Aristotle says phronesis requires experience and this is not possessed by the young. He says that. Young people are incapable of possessing phronesis. This is why clinical education is so long. It's a kind of hot house designed to age people rapidly. For clinical medicine embodies a persistent problem in philosophy the application of general rules or principles to the individual instance. Physicians can't take care of patients out of textbooks. In fact the first edition of evidence-based medicine said Burnham they're old and they don't apply to the individual case. It's medicine's character as a practice that's exactly why physicians can't be replaced by computers. What's essential to practice then is interpretation and textual skill. Hormoneutics which has been called the science of interpretation. I don't know what they mean by science. The knowledge of interpretation. In medicine that interpretive skill is clinical judgment. It manifests itself as habitus an ingrained response that's both cultural and individual. Bourdieu points out that habitus gives practices their relative autonomy by which he means more or less their independence from proximate cause their appearance of sort of coming out of the blue as well as an appearance of retrospective necessity. Sherlock Holmes finishes explaining to Watson and Watson says well of course but he couldn't have seen it beforehand. And this leads him Bourdieu to his most interesting observation that practice excludes from its experience any inquiry as to its own conditions of possibility. What you know is what there is that's it while you're in motion while you're acting. This non-conscious unwilled avoidance of epistemological questions will conclude that the truth of practice is a blindness to its own truth. Such individually embedded cultural automatism is in fact just what clinical education aims for an ingrained capacity for assessing the best information at hand and acting as others educated in the same culture or profession would or at least in ways those others would recognize and accept. Bourdieu's concept of habitus is practical reasoning or phonesis understood in its cultural context a kind of knowing or embedded tact that some might label intuition. Within its culture such knowledge seems natural and automatic like Sherlock Holmes's deductions which by the way aren't deductions they're what's Charles Sanders' purse called extraductions or abductions abductions starting from the cause sorry starting from the effect and moving to the cause it's backwards if you like compared to what we think science is. Such knowledge like Sherlock Holmes is often astonishing to outside observers the process of clinical judgment as habitus erases itself and becomes invisible. Those who possess it take it for granted like people who are experienced drivers they just know have you tried to explain to someone how to drive a car I mean it's just crazy it's hard enough when you're sitting there besides your teenager to remember the things to say but to do it without actually being there is almost impossible clinical clinical medicine is or operates as if it were a common sense cultural system and the aim of medical education is to make it so the physician's practical rationality is culturally engendered communally reinforced situationally sensitive and interpretive even if in the case of a doctor in solo practice the dialogue the community the interpretation are all internal this I think is where medical professionalism resides there habitus clinical judgment phronesis there are multiple distinctions among these concepts I've clustered here but they all represent a kind of knowing that's not hypothetical deductive not episteme or scientific knowing but nevertheless deserve the label rational those who possess this rational capacity in great measure are often said to be wise why then is medicine regarded by the media by patients and by many physicians as a science why in medical education is it often presented that way even though clinical education is strongly experiential it's pure John Dewey it's learning by doing but that's not what you hear that's not the words that get said we could recognize the practical nature of clinical rationality and teach about it but for some reason in medical education we accept the assumption that medicine is in the old fashion Newtonian sense a science what we learned in high school high school science unless you're sending your child to a very expensive school maybe even then you're not getting your money's worth high school science is taught as here is the logical way to know the truth about the reality of the physical universe what you discover is what there is all there is for a long time in fact two years when I was writing how doctors think I was afraid that this might be some version of what I call the centipede problem and here's a slide you haven't seen I hope believe me this is the best looking centipede on the internet but you don't want to see the ones in full technicolor you know the story the centipedes ask how it can walk with so many legs and it stops to take thought and falls over so I wondered would physicians be incapacitated by thinking about how they think or students fail to learn if they weren't told that they're engaged in a science Hans Georg Gottemar his account of what's going on with practices suggests not he writes practice requires knowledge which means that it's obliged to treat the knowledge available at the time as complete and certain in the moment of action physicians don't think about how they think they can't they're otherwise engaged so we and they are in no danger of their stalling out of falling right over the ethics of practice trumps any epistemological curiosity that they may have this won't change no matter what scientific advances are made when our genomes are entirely sequenced and matched with every conceivable physical and mental disorder medicine will still be a practice the attentive focus on the particular patient that's the clinician's moral obligation will continue to compel the exercise of practical reason this duty is at the heart of medicine's ethos it's professionalism it's this attentive focus that medical educators should inculcate in new clinicians not with injunctions to be scientific but with reminders and demonstrations of the ethics of practice so to summarize professionalism is not merely etiquette or workaholism or guilt from your peers for not being the guilt the guilt that peers inflict when you might go to a child's soccer game and it's not thinking like a scientist it's the acculturated habit of thought and action that's deeply ingrained and largely unaware of itself our failure to recognize this practical rationality leaves us with a sterile scientific view of the way physicians think and thus of the nature of their work this has ill effects for patients for clinicians and for medicine in society the current interest in professionalism aims to remedy these ills but to succeed it needs a better understanding of the centrality to the profession of an interpretive clinical judgment thank you what do you think recognizing that medicine is a practice and maybe the science isn't as important what are the implications for that with our restrictions on access to medical education with certain standards for science that people have to have with their scores or the knowledge coming in and what does that mean for how important science might actually play a role being in my preclinical years and studying the science part science is really important though I must say at one McLean scholars lunch six or seven years ago I had something to say they invited me to come talk about something and it was it was the year I don't know when when there were several oncologists just to scare you to death several oncologists in the group and they kind of conferred among themselves and they said we don't think about science you know maybe five percent of the time well this is the wonderful thing about system one and system two theory because of course they don't think about science they don't work it out anew but it's gone into all their decisions if you've looked at Malcolm Gladwell's Blink he begins well he begins with lots of little stories but early on there's a story about an art expert at the Getty in California who looks at some Greek statues and says uh-uh and they actually test they do the science they test the stone they do all kinds of things he says not their fakes I can't tell you why I know but they're fakes and it's because he's looked at these things all his life and thought about them and seen the results of tests and you know knows all the theory and practice of authentication so you need that science yes you have focused on the idea of phronesis as the intellectual virtue that physicians have but you focused on it that way as a capacity for judgment for figuring out what to do now one distinction that Aristotle makes between virtues and skills is that skills are things which once you know what they're about you can choose to do them or not to do them whereas if you have a virtue if you have a certain kind of human excellence you have to settle this position to do what's required and indicated by that virtue whenever the triggering conditions obtain so what I would like to know and that's therefore Aristotle's phronemos is a person who but does it and so when asking about medical professionalism using Aristotle as your model here does that include the virtues of character that would mean that physicians and other healthcare professionals will be reliably habitated to coin a word actually to do whatever it is that professional norms in their judgment require that it will be so to speak not really possible to judge accurately what to do and not to do it that would be Aristotle's account I didn't go there I figured you heard a lot about that this whole year and I don't know much about it that is you know I read people opinions but I'm concerned with arguing for practical reasoning as central to professionalism and I didn't call it a skill actually I called it a capacity and I believe that you don't have a choice whether to do it or not once you're a doctor I once had this I started to put this in the talk but it's coming out of my mouth anyway you'll see why I hesitated to do that I was once at a modern language association meeting about 10-12 years ago an English professor at a well established university came up to me before my presentation and said I've got to talk to you after your talk I'm going to any named a prestigious institution medical school in the fall and I was just overjoyed because this institution is at the forefront to use a UFC word of of we've got what is it never mind I won't say when residents get lab reports back on time they say amazing things happen anyway he said I'm going to any named the medical school and I was really pleased because this medical school is at the forefront of ethics in medicine, ethics in education, ethics in graduate work for people who will go and teach ethics in places and it also teaches medical students so I was just delighted I thought finally some literature in university and I gave my talk and he came up afterwards and I forgot to say he was 35 or so and he said well first words out of his mouth I realized he wasn't hired to teach he was changing careers he was going to medical school and what do you suppose his question was and this addresses this capacity because I think it's irrevocable it's inalienable he said is it going to change me and what would you say to that I was so shocked that what I blurted out was I hope so I hope so it's going to make you a doctor and this is true of the professions generally if you've been a person of the cloth a priest and you leave that profession you're still you're still got that as part of your character same for doctors even if they're bad doctors and get thrown out maybe that's still true anyway I won't speculate about priests and it's true of lawyers I mean people who go to law school and practice law and then change for something else they say oh I'm not a lawyer anymore but don't get into an argument with me because I don't I don't want to be I don't want to lose I think that professionalism that innate capacity to think clinically is formed in the clinical years using all the stuff that you learn in the first two years and you never lose it you're a practical reasoner for the rest of your life thank you very much for coming