 Welcome to today's session of the Professionalism Seminar series. We're absolutely delighted that our two colleagues could join us today. Farr Curlin and John Yuen. Farr is from the General Medicine Division, and John Yuen is from the Hospitalist Section in the Department of Medicine. They're both working on a long-term project on the good physician, which will be a longitudinal study of the development formation of medical students. And today they're going to talk to us on the topic of can virtue be taught? Actually, can virtue be taught to physicians? Contemporary investigations of a timeless question. I'm eager to hear the presentation. Really, are we close? We're close. Good timing. Well, thank you, Mark. And John and I and our colleague Ken Rysinski is here. Yeah, there he is. He's very bad. Have been working on this project together. It's going to be the one volunteer to stand up here, and then John is going to help me make sure I answer questions correctly. This is a project that began a few years ago as we sat around asking ourselves the question. How would we know whether all of these different interventions that medical educators use to try to make doctors come out of the end of medical training as good physicians or in the terms of this seminar with professionalism? How do we know if those things are working? What is it, in fact, that goes into the formation and the development of a physician who is characterized by the kinds of attributes that we would hope they would carry? And is that something that is more or less decided when they enter? How much does the medical education and medical training process really make a difference? And if it does make a difference, what parts of it make a difference? So that was a conversation that we had. And then we've set out to try to figure out a way to empirically measure this. And what we want to do today is invite you to hear about that journey of ours up to the point where we are now, which is very much in midstream. And as Mark said, we hope to develop a study that will become a longitudinal study that goes on for several years, and I'll explain that. But we are just beginning now. So this is a good moment to get more feedback from colleagues who've been thinking about these issues in your own walks and in this, as you've participated in this seminar. So again, the project comes out of a question that's very much at the heart of this year's seminar series. By the way, can you guys, am I standing too much in the way? Is this a okay spot? All right. Okay, thanks. How does one become a good, that is to say, you think I should turn it, virtuous physician? This is Sir William Osler, once called the saint at Johns Hopkins, and as Dr. Sulmasey and other Hopkinsites can tell us, there's still certain forms of worship and devotions that go on to Sir William Osler. And for good reason, widely recognized though, I think, as an exemplar of the good physician. So we're asking ourselves here, how does one become such an exemplar, even if in more modest terms? And the timeless question rears itself with some force in contemporary American medicine, because while today's medical science has steadily grown in its powers to cure disease and alleviate suffering, the American public, and this may be perhaps paradoxical, the American public has been steadily losing its trust in physicians. So this graph shows data from the General Social Survey, indicating that over recent decades, the public's confidence in the medical profession has steadily declined. Why would that be? In his book, Trusting Doctors, The Decline of Moral Authority in American Medicine, the sociologist Jonathan Ember hints toward one possibility. He argues that Americans once viewed medicine as a sacred vocation, but now physicians have become more valued for their technical competence and for their noble character. That's his quote. Ironically, the field of bioethics may have unwittingly contributed to this decline by focusing on the procedural dimensions of clinical decisions, often at least, rather than on the moral agency of clinicians. So there's been a lot more work focusing on whether something is permissible, and with respect to that, whether the appropriate decision-making procedures have been followed. Think about how much time we spend in medical ethics case conferences asking whether someone has decisional capacity, whether that's been assessed properly, how we respect their autonomy, focusing on substituted judgment, the procedures of informed consent, et cetera, and much less time on the question of how do we inform good decision-makers, people who would have the habit of making the right decision. Leon Kass once said, though originally intended to improve our deeds, the practice of ethics of truth be told has at best improved our speech. I think that's an overstatement. But bioethics focused on moral dilemmas does seem to divert our attention in the profession away from questions related to the moral character of physicians and the virtues needed for the good practice of medicine in our world. And in response to these trends, there have been many medical organizations, we've been hearing about some of them over the course of this seminar, that have launched major initiatives to teach physician professionalism, as it's called, as a core competency in medical training. In this seminar series, with the language of professionalism it adopts, is one outcome of such initiatives. The University of Chicago has its own professionalism ventures. But even here, little is known about whether and how these efforts actually shape the character and the practices of physicians. So that's how we got into this project. And at the outset, we recognized that as scholars from many disciplines in social science and in philosophy have recognized, medical training includes a process of moral enculturation, through which physicians and trainings acquire not only technical skills and specialized knowledge, but also come to take on those values, attitudes and durable characteristics, virtues and vices you might say, that make for a more or less good physician. So our question was, how can we take advantage of this natural experiment in moral enculturation and formation that is medical training to find medicine's contemporary answer to Plato's ancient question via minnow to Socrates? Can virtue be taught to physicians, or if not, does it come by practice, or does it come neither by practice nor by teaching, but by nature, or in some other way? I think that question rings very relevant to us in medical education today. Interestingly, in an editorial a decade ago, Dan Solmacy drew upon this question and pondered whether medical schools themselves could be transformed into schools for virtue. He wrote there, the cynics will contend that virtue cannot be taught, that students come to us already morally packaged and incapable of change. The data shows that students can and in fact do change. Unfortunately, this change is in the wrong direction. And indeed, many studies of medical trainees bear out Dan's observation. So again, why is that the case? What are the causes of this moral decline, if you will? And which of those causes are the most important? And what factors might mitigate a tendency for physicians to grow less rather than more virtuous over the course of training? To answer these questions, what we need, we think, at a minimum, as I want to say up front, we think this is a very hard thing to study empirically. And we're trying, and we think we have good reasons for how we're trying, but this is a tough subject to study, and we'll see some of the reasons why. But what we need at least is a longitudinal study that would follow national cohorts of physicians from matriculation to medical school to several years after completing postgraduate clinical training, measuring along the way the key variables, the ones, the variables that matter. We would expect up front that individual characteristics, durable characteristics of that medical trainee and contextual factors, both curricular and other aspects of their experience in training that would make a difference, that there'd be both virtue sustaining factors, virtue inhibiting factors, and that there's an interact in some complex manner to determine the extent to which medical students develop and sustain those characteristics that we would admire in a physician. And a longitudinal design would allow researchers to assess the interplay of those factors over time. Interestingly, no such study has ever been done in the United States, so we set out to try to lay the groundwork for it, and over the past year and a half we've conducted a pilot study, which I'm going to describe further. This is a national medical student survey where we conduct, where we collect data at two points over time. Two points is the minimum imaginable longitudinal study, and that's where we wanted to start, because we wanted to see what does it require to pull this off? Can we get people in? Can we gather data in these different ways? Some experimental ways I'm going to describe. And again, staving off your disappointment at the end, the data I'm going to present from this is very early, and it's only from the first wave of data collection, because we're in process of finishing data collection on the second time point. All right, here were the objectives for this project. First, to build and test an administrative architecture for effectively fielding a longitudinal study of physicians in training. The idea is that this study would follow in the tradition of the great longitudinal educational surveys of past decades, several of which have been done successfully, while taking advantage of some of the unique capacities and efficiencies made possible by today's computer-based survey technologies. The second objective is to develop and refine robust measures of generosity, medical generosity, empathy, and mindfulness in medicine. And we'll discuss the rationale for selecting these particular virtues in a moment. And the third is to examine students' narratives of their professional formation and development over the course of medical school. So, Alasdair McIntyre was one of the first speakers in this seminar, and his work over the past few decades has a central theme of it, has been the argument that virtuous practitioners of any practice, take any kind of human practice, understand their work as fitting into a life narrative that involves a quest for the good, for what is worthy, for what is virtuous, through the harms, dangers, temptations, and distractions encountered on the way. That when you think of a good practitioner, they have a sense of sort of a commitment to something good in this work, and how this work fits into it, they see it as an effort that involves not necessarily an easy path of avoiding ways of falling off track. And we want to know how students think about their work potentially in a way that relates to that framework. That would involve obtaining qualitative data, which we are just beginning to do, using a narrative interviewing method that a colleague of ours, Dr. Dan McAdams at Northwestern, developed in generating life stories around what it means to be a virtuous person. And the idea is to adapt this to focus on physicians' life stories around what it means to be a virtuous physician, a good physician. A central challenge for any empirical science of virtues is to specify the characteristics most relevant to a particular domain. There are, in this case, medicine. And then we have to find ways to empirically measure those. And we're mindful here of Aristotle's admonition in his Nicomachean ethics to not demand greater precision and certainty than a subject will allow. So you're going to have to... Well, you'll see. This is going to be an imperfect set of measures, and I think that's of the nature of this. But here's how we proceeded. So we begin with McIntyre's definition of virtue, which is essentially his formulation of Aristotle's account. Quote, a virtue is an acquired human quality, the possession and the exercise of which tends to enable us to achieve those goods, which are internal to practices and the lack of which effectively prevents us from achieving any such goods. We then follow the physician philosopher Edmund Pellegrino, who also spoke in this series, who applied McIntyre's reformulation of Aristotelian virtue ethics to elaborate those virtues that are essential to achieving the goods internal to the practice of medicine, namely the preservation, promotion, and restoration of health. So putting these together, we might say that a medical virtue is an acquired human quality, the possession and the exercise of which tends to enable a physician to achieve the preservation, promotion, and restoration of health, and the lack of which effectively prevents physicians from achieving these goods. Now, there are many medical virtues. And for this study, we could not focus on them all. And after a lot of thought and discussion, I won't go into the details of that, we chose to focus on three. Empathy, I'm sorry, yeah, mindfulness, well, in generosity, empathy and mindfulness. Why these three? Well, first, these virtues are central to the doctor-patient relationship and to the good practice of medicine across virtually all specialties. In other words, physicians and patients, I think, can generally agree that these are virtues that are essential to being a good physician pretty much no matter your specialty. There may be a couple of specialties that doesn't matter. Like pathology, I don't know how much empathy I need to be a good pathologist, but pretty much across the clinical specialties. Second, the field of positive psychology has done a lot of work to develop validated measures of these virtues that can be put in a self-administered survey. And though we would like to assess the virtue of prudence or good clinical judgment in medicine, we've not come up with a feasible way of doing so using self-reported survey items. We hope to, but we haven't yet. Third, these virtues are considered foundational and leading theories of virtue development and mature moral functioning. So for example, scholars from various disciplines and particularly the fields of moral and social psychology have described mindfulness and empathy as sets of metacognitive skills. Mindfulness focused on the self, empathy focused on the other. Mindfulness is one manifestation of a metacognitive skill that promotes moral self-reflection, self-monitoring, and an active attention to one's thoughts, motivations, and actions. And similarly, empathy can be thought of as a metacognitive skill that allows us to understand and respond adaptively to others' emotions and to promote pro-social behavior. It's not, I don't think, accidental that both of these are very central to efforts within medical education to try to, again, develop good physicians, to add something to the development of physicians. In this way, mindfulness and empathy serve as metacognitive precursors that are necessary for the formation of most, if not all, other virtues. Generosity is expressed in a variety of altruistic and pro-social behaviors, but we, being focused on medicine, we're interested specifically in what's been called interpersonal generosity, which is the form of generosity in which an individual spends herself, so it gives her attention, her time, her emotion, her energy, et cetera, in service to others. For those in medicine and other helping professions, seems to us that generosity would be a crucial marker of moral maturity. And that rings, seems to ring true to most people. We think of these three virtues as related to one another in an order of dependence so that in order to perform particular acts of interpersonal generosity, you must have a habit of empathic concern. And in order to develop empathic concern, you have to have the mindful capacity to step back from your own thought processes and actions to recognize and appreciate the thought processes and actions of the other. Now, early on, we scoured the literature and talked to our advisors and other experts in the field to select existing measures of generosity, empathy, and mindfulness, and then we developed novel physician-specific instruments to measure these virtues. You can see here, for example, you have the Loyola Generativity Scale that's been used widely in different population samples or the Interpersonal Reactivity Index been used again by psychologists in multiple different populations, the Five-Facet Mindfulness Model. And these Chicago versions are our forms of adapting those to the field of medicine. Let me just show you a flavor of how this was done. So here are examples of the Chicago Physician Generosity Scale. Each of these scales has 10 or 12 measures. Here's a few of them excerpted. I go the extra mile to help take care of my patients. I make time to pay extra careful attention to patients' problems. I eagerly look for moments in which I can teach patients something helpful to them, or the empathy scale. I try to imagine myself and my patients' shoes when providing care to them. I can tell when patients are sad even when they do not say anything. I listen carefully to my patients when they need to get something off their chests. Mindfulness. In my clinical work, it seems like I'm running on automatic without paying much attention to what I'm doing. Has anybody here ever felt that way? I overlook clinical clues in a case because of carelessness or not paying attention or thinking of something else. After a difficult interaction with a patient or colleague, I try to slow down and think over why I behave the way I did. How often is this true for you? Now, you may be asking yourself as we, as certainly I was, why would I trust someone else's judgment of how generous they are? Why should you trust my judgment of how empathetic I am? I think that's a very important question. The social psychologists have worked hard at these measures, but I think there's this really, if you think about the virtue theory at least in the philosophical field and to go all the way back to Aristotle, the virtues of a person are really best discerned by the many and the wise, as he said. They're best discerned by the observations of people who are themselves virtuous because they're the ones who really know what virtue is and you can't just pick one of them. Now, how can we get the many and the wise to weigh in on whether Dr. Siegler or Dr. Yoon is empathetic or generous and so on? What we're going to do is, and this is one of the novel things that hasn't really been done, at least not in medical education in this kind of a study, is to use peer ratings. So people have consented in the first data collection point in our survey to be a part of the second part, most of them have, in which they're going to go on a website and they're going to see the names of their classmates who are also part of the study and they're going to rate those classmates on several different physician virtues, including a final rating on a kind of, I forget how it goes, but something like, to what extent you would trust them in the care of your loved one, to be involved in the care of your loved one. And we're going to see whether those measures appears to what extent they cohere with or correlate with people's measures about themselves. One hypothesis we have is that the group of medical trainees that's maybe most morally problematic or needs to be watched are those who have rate themselves very high and their colleagues rate them very low. Okay, let me press forward a little bit just to tell you what we did. Last year we surveyed 963rd year medical students from 24 schools. Now, although there are 133 U.S. allopathic medical schools, we chose a sampling method among schools to ensure that our national sample represented students from a range of different school characteristics, such as public versus private. We wanted to sample from all four U.S. census regions and from schools throughout all levels of ranking scores, both from the U.S. News & World Report and from social mission score rankings. We selected only third year students because of interest in sampling students with some clinical experience in working with potential role models in medicine and because these clinical experiences are where you start to see expressed, at least in theory, the characteristics that are the medical virtues. And as of today, through a combination of mailed and online questionnaires, we've obtained an adjusted response rate of 63% of the people we send out surveys to. And we're on the verge of completing the second data collection and we have so far a response rate of more than 80% of those who completed the first data collection point have responded to the second. In addition to filling out a paper and pencil questionnaire, we ask students to go to a secure website where they provide email addresses and other contact information and they do some open-ended, open-ended items which, again, is starting into that question of their narrative of their experiences in medical training. I mentioned before we're about to do these qualitative interviews and just to focus on that a little bit, the idea here is that the life narratives might be sensitive to the influence of their environments and context on their students' moral formation and character development. So you guys have all heard the term of the hidden curriculum. So the ideas embedded within the hidden curriculum of medical education are a wide array of narratives containing both villains and virtuous protagonists that students consciously or unconsciously adopt during the process of their professional character formation. And these narratives are often transmitted and perpetuated by clinical role models who exert a powerful influence, we imagine, on the moral formation of physicians and training. So we expect that students' narratives will reflect a struggle, their struggles to exhibit virtue in learning environments where such virtues are not always honored or rewarded. And we're all familiar with this, people talking about how hard it is to really care about your patients if you don't see people around you caring about your patients. Humans are storytelling animals, McIntyre notes, and in classical society, the chief method of moral education is to track cool hand and they're using literature and medical education. Story narratives function to establish physicians' professional identity by setting the plot and subplots of their work with its themes and particularities and set it into the context of a unified virtuous life. So the efforts to analyze their narratives we hope will enrich our understanding of how these virtues are sustained or inhibited in the experience of medical training. So we're going to talk about that. Again, by the way, much as we did with the medical schools, we do these qualitative interviews by selecting on student characteristics. So we're going to select some of those students who are rated by their peers as on the low end of the physician virtues or rate themselves anyway and their measures on the low end. Some of those are on the high end. Some of them particularly have high academic performance, some of them maybe don't. And then we're going to and there's a few other characteristics we're interested in. All right, to give you an overall idea of the characteristics of our respondents, these slides display their demographic characteristics. They're pretty evenly divided, as you can see, between gender by gender, distributed across region and across schools from all ranking levels of social mission scores. They are distributed in ways that are pretty typical of ethnicity, immigration status, and we also measured student debt, which we think has an important role in some of the questions we're interested in. Now, this is a busy slide, but I won't go through all of this, but if McIntyre's right, virtuous practitioners seek goods internal to a practice itself. That means they don't do the practice in order to get wealthy. They don't do the practice in order to get esteem from other people and so on. They do it because it's good in itself to do it. None of us is that way entirely. We are human after all, but the more virtuous folks at least in theory should be after the goods inside the practice. So to get at that somewhat, we asked about a sense of vocation or calling in one's work as a physician. And we included other measures from work motivation and life satisfaction and if practical wisdom leads to what the Greeks called eudaimonia or true happiness, we would think that physicians with higher ratings on the medical virtues will find their work more meaningful and will be more fulfilled in it. We'll have to test that. We don't know that yet, but we asked students to indicate how satisfied they are with their work in medicine. With respect to predictors include a list of variables that are associated in prior research with physicians' career choices and specifically their practice among the underserved, which we think is one way of expressing generosity. Not the only one, but one that we're interested in. That includes demographics, personality characteristics, undergraduate major, immigration history, educational debt load and so on. And we include some measures of moral foundations and intuitions from Jonathan Haidt's work if any of you know that and religious characteristics extending my own interest in the intersection of religion and the practice of medicine. We also asked respondents about what we believe are potential facilitators to the development of medical virtue. If you look on the right-hand side of this slide including one of our high policies that a desire to follow in the footsteps of an exemplar physician and an exposure to people who they would identify as clinical exemplars helps them become like those that they admire. We also measure factors that we believe pose obstacles to the development of virtue and here we're going to focus a little bit on burnout, which has been shown or it's been described in the medical literature pretty extensively as a real obstacle to the flourishing of physicians and to their development. We also added a measure at the strong encouragement of our colleagues in the world of psychology of entitlement. Which in the general psychological literature has emerged as one of the chief obstacles to the development of virtues and which we with hypotheses would affect the development of the virtues in medicine as well. So you might even draw to your mind, take a minute draw to your mind someone you think is pretty entitled one of your colleagues and ask yourself that maybe is, that's maybe a marker of a problem in their development. So here's just a pie chart on one of our items about people's interactions with role models we asked them who is the physician you most admire and then we had them answer a few characteristics about them 60% roughly identified someone they'd worked with on the wards in medical school. Other big categories were a personal or family friend remember I don't remember the exact percentage but a significant number of doctors are family members, have family members who are doctors and then a preceptor or mentor they sought out themselves or assigned by school. Anyway then we asked them to what extent does the your choice of, let me just say this exactly does that, what is to what extent does your desire does desire to follow in the footsteps of a physician you admire influence your specialty choice. This is asked right after we've asked them to indicate which specialty they intend to go in at this point in time they're not all going to be fully decided and interestingly about half of people say little to no influence but about half say some to a lot to a few say the most possible influence now we then asked we then looked, we didn't ask them this, we looked at the specialty of the physician they identified as the one they admire most and especially they say they're going to go to themselves and among all the students and these specialties are pretty granular so we have I think 12 or something or 15 sub specialties about 14% of folks identify the same specialty and then just as an affirmation of some substance of that prior question we see that among those who said that a desire to follow in the footsteps of a physician and influence their specialty choice about 23% said they're going into the same specialty versus 12% among those who said little or no influence that both shows that there's something there and then it's not terribly powerful at least in these data here we have the mean empathy scores this is around those scales 10 or 12 item scales for the respondents and we've broken them up in the blue are people who have we've dichotomized and have low burnout scores and in the maroon are people with high burnout scores and basically what this shows is that you see a modest but at least in the case of medical empathy significant reduction or lower levels of empathy among people who identify themselves as burned out and in the future we'll make these more graded and you'll probably see stronger relationships for the ones who are really burned out but here we just dichotomize them as an illustration here just for those of you social scientists in the group just you see first with respect to general empathic concern an alpha score of 0.79 which is a measure of to what extent these different items that they people responded to are measuring the same thing that's pretty good with the medical one it wasn't quite as good but still solid and we do find that people's empathy in general is correlated with their empathy in medicine as you'd expect and that the correlation is it's pretty strong but it's not complete frankly we wouldn't want it to be complete because then you might as well just ask about their general empathy and we can at least imagine that there are people who have really cultivated in their practice habits of empathy that may not fully transfer over to the rest of their life and vice versa first of all we want to this is where we are today we want to clarify how best to measure a virtue that means we need to assess to what extent self-rated measures of virtue correlate with peer ratings that's one thing we need to do to measure virtues and of overall excellence in a physician trainee as judged by one's peers and then related to that we want to examine to what extent different pre-medical school characteristics predict who will come to be characterized by medical virtues toward the end of medical school this is Andy's question so one of the couple things we're interested in because these are things used in selecting students is to what extent are intellectual horsepower as measured by say MCAT scores a predictor of whether they're going to be recognized by their peers four years later as outstanding to what extent does prior community service predict that they're going to be recognized by their peers as generous and we also want to look at how traditional measures of academic performance specifically grades and class quartile and AOA and so on are associated with measures of these other physician virtues and of students rating of their peers we get to two data points we can then start to look at your Steve's question which is what's the chicken and what's the egg here if you take empathy and burnout you can imagine I can imagine a plausible story in which the person who declines in virtue therefore declines again thinking about this theory of moral formation and virtue they stop finding and seeking and finding intrinsic goods in their work so they start to only make sense of their work as a way to get something maybe it's to please their parents maybe it's to not you know to figure out a way to pay off all that debt they've accumulated you know it's to get a well we can all imagine stories like that and those people are going to be in this theory are going to be more burned out because that's just not deeply satisfying to do something for extrinsic rewards is not as satisfying as doing it for the intrinsic rewards in that case we'd expect to see over time that when someone's when someone starts to lose a sense of medicine being a worthwhile way to live a good life then they start to become burned out and but the other story that makes sense is they start people are trying hard to do their best they love medicine and so on and for whatever reasons they're trying to burn out they're exhausted they're struggling to keep up with what they think is the minimal necessary to really be doing a good job and when they burn out then they become jaded and they're so exhausted they don't have the psychological and moral reserve to express the virtues to even be empathetic to patients and we can't tell that until we have multiple time points and even two is going to be really hard to see so we're going to need to see it over time Thank you all for your attention