Richard Cruess on professionalism and identity formation in medicine, and the dual role of physicians as professionals and healers
“Teaching professionalism means trying to help medical students develop a professional identity as a physician so that they think, act and feel like a physician.”
By Devon Phillips. Richard Cruess is no stranger to leadership or to passion. The brief list of his leadership landmarks include having served as the Dean of the Faculty of Medicine at McGill University from 1981 to 1995, as well as being Professor of Orthopedic Surgery, Companion of The Order of Canada and of L’Ordre National du Québec, and a Core Member of the Centre for Medical Education at McGill University. But it’s a passionate third career that he is now pursuing with his wife, Sylvia Cruess. Together, they are very busy partners carrying out and publishing independent research on professionalism in medicine. They have published widely on this subject and have been invited speakers at universities, hospitals, and professional organizations throughout the world.
Q: I understand you have been enjoying a new career teaching as well as conducting and publishing research on professionalism in medicine. How did you become interested in this topic?
A: Twenty years ago, when I stopped being Dean of Medicine at McGill, and my wife Sylvia stopped being the Medical Director of the Royal Victoria Hospital, we took a sabbatical year together. I had a project to look at the impact of government policy on academic decision-making because during my time as Dean, I had been beaten up by government ministers. Sylvia, as Medical Director, said there were a bunch of people who were generally pretty good but they did not behave in a professional way so she wanted to study professionalism in medicine.
Q:Tell me about your sabbatical year.
A: Our sabbatical year was in Princeton and in Oxford 1995-96. We did a big literature search. I started looking at academic freedom in medical schools. I got about 1,000 articles on tenure which did not mean very much. When Sylvia did her literature search for professionalism in medicine, she got an enormous amount of stuff, mostly sociology, but also philosophy and religious studies, but none in medicine. There was not a single article on professionalism in medicine.
Q: What did you make of these findings?
A: It was rich wonderful literature. It was quite clear that the sociologists knew us a whole lot better than we knew ourselves. The founders of sociology, Brandeis, Flexner, and Parsons, all wrote about professionalism. The literature went back very far because medicine is the archetypical profession but nobody in medicine was reading it, or, if they were reading it, they weren’t using it. Sylvia and I had thought we would retire and go fishing, but we came back and decided that after having spent a full year reading and thinking, we weren’t done. So we spent almost two wonderful rich years researching and reading- it was like a graduate degree. Our first article that came out in 1997 essentially brought the social sciences literature into medicine and it has been a hugely cited article. There was total agreement that our professionalism was being threatened by a whole host of things including our own failures, failure to self-regulate for example, because our self-regulation was deeply flawed. We protected doctors; we didn’t hold them to the standard. And we were threatened by modern healthcare and by the cost of modern healthcare too.
Q: How is modern healthcare a threat to the medical professionalism?
A: If you go back to 1940, 2-3 % of the GDP [gross domestic product] would go to healthcare. When Medicare came to Canada, 5.5% of our GDP went to healthcare and the Americans had 5%. Now we are at 10% and they are at 18%. Also a lot of people started to make money in healthcare. So all these things meant that efficiencies had to be put in place. Essentially in a government-run healthcare system, we had to arrange for the most healthcare with the least money for the most people, and boy, that interferes with the autonomy of the medical profession.
Q: What is professionalism in medicine?
A: For the last 20 years we have been amongst a group of early pioneers in making people understand that there has to be definition of professionalism. And I thinkwe were the first who noisily advocated that it had to be taught. The previous system depended on relatively homogeneous medical professionals who became professional by patterning their behavior on role models and that worked when life was not very complicated. Now you have to be teaching and assessing professionalism at both the undergraduate and residency levels in order to be accredited. So all of a sudden, from professionalism being something implicit, it is now an explicit part of the formal curriculum. Working with colleagues, we developed a definition of professionalism, built an interactive curriculum for teaching professionalism and have published everything that we have done, including a book on teaching medical professionalism ̶ that’s the only book out there and the 2nd edition is coming out this April. And we devised a means of teaching it and of providing guided reflection because there are real issues of tension.
Q: Within professionalism, what are the issues of tension for medical students?
A: Currently, students are insisting on lifestyle balance so we force them to look at altruism versus self-interest and lifestyle. We ask our students to decide what they are going to do if their grandmother’s 75th birthday is taking place the same time they’ve got a patient in the emergency room. We also force them to think about self-regulation because The Royal College of Physicians and Surgeons is a physician-run organization and we are responsible for the behavior of our colleagues. We design situations where they have to think about the social contract between medicine and society.
Q: What is the social contract?
A: Medicine is given privileges ̶status in society, money, autonomy, but with the understanding that doctors must behave in a certain way. We make our students think about how they are going to be able to meet public expectations and where they won’t be able to do. And because it’s a social contract we ask them to think about where society is not going to meet their expectations in the practice of medicine.
Q: What is your thesis about the role of physicians?
A: Our thesis is that, and this is the way the curriculum is designed at McGill as a result, in day-to-day life, physicians fulfill two roles: healer and professional. Healers have been with us before recorded history whereas the contemporary professions developed in the middle of the 19th century out of the guilds and the universities of the Middle Ages and society uses professions to organize the services of the healer. Professions are established by law; we are licensed and self-governing and that means that society doesn’t have to organize doctors and train them. But the healer role is different, and you cannot go to a student and talk fuzzy wuzzy about being a healer. The role of the healer has to be defined and a method devised whereby it can be communicated and reflected upon. Healing is essentially whole person care but it leans heavily on palliative care. But people who have common colds need healers too, not just people who are dying. I’m an orthopedic surgeon and if I have a lady with a broken hip and she doesn’t know if she is going to be able to go back and live independently, I have to be a healer!
Q: How are you getting the word out about your research on professionalism?
A: We have given about 260 presentations outside of Montreal on what we’ve done. For a while we were in the air constantly and wherever we would go somebody would ask:“Can you really teach professionalism? Can you make professionals of people who are unprofessional?” And we could answer that we can provide a framework from which people can address issues. This is how I have always justified the teaching of ethics. We cannot make an unethical person ethical but we can take an average person and help them solve issues. Two or three years ago some really bright people starting talking about identity formation and the lights went on for us.
Q: How do you define professional identity formation?
A: We have changed the focus from “doing” (meaning behavior) to “being” because that is who you are. So what we and other people, those in developmental psychology, have known for ever, from Aristotle to Shakespeare, is that people go through developmental stages and those stages go on throughout their lives. Erikson and more recently Robert Kegen, have identified these stages and our medical students are about half or two-thirds of the way through the developmental process. Their identities can still be influenced and of course they want to acquire the identity of a physician, that is why they go into medical school. So we are not doing something to them that they don’t already want.
Q: Are you adapting the curriculum to address this changed focus?
A: What we’re in the process of doing is switching our curriculum. We have changed the educational objectives of these courses from teaching professionalism to supporting students as they develop their professional identities. We have always started on the first day of medical school, Sylvia, Don Boudreau and I and Tom Hutchinson have always been the first people to talk to students about identity formation. We tell students that you have to partially deconstruct who you are in order to become something better and that cannot be done without some stress, so you have to manage that stress. Role models and experiential learning are important, both of which are more effective if you provide guided reflectionon the experiences.
Q: What’s the response from students so far?
A: Enthusiastic! We are talking about fundamental issues. We are talking about the essence of being a physician and whether they are going to be able to handle it, what’s worrying them, and what forms their identity. If you join the medical profession you have to accept the norms and if you don’t, you are going to have trouble.
Q: Do medical students feel they are at odds with what society wants of them as doctors?
A: There are big generational issues. The most serious is lifestyle versus commitment to the patient and this is related to work hours. Nobody disputes the fact that previous work hours were abusive and there are a whole lot of surveys indicating that students in North America look at being a doctor as a job rather than a calling. People sort of laugh when you talk about “calling” so you don’t use that word anymore. Doctors over the age of 55 cannot comprehend this because being a physician is so important to our identity.
Q: Are the expectations of a student going into medicine very different to when you went into medicine?
A: Yes. And part of it is because of the increased number of women, but it is interesting that men now want the same things that women do: more regular hours, less commitment, more time for other things. The law schools are having the same trouble. Young lawyers are pushing back so it isn’t just in medicine. It’s a societal change.
Q: Do you have a special interest in palliative care?
A: Yes, and that’s true for those of us who were at the Vic [Royal Victoria Hospital] including my wife and I. Every single person who had administrative responsibilities, and I was in orthopedics, had to come to terms with Bal [Dr. Balfour Mount] one way or the other! Bal was a very disruptive force. How do you think he could get money and beds in a hospital? He never gave up. And it was either, “No way we are going to have to be devoted to this dying stuff,”or it was, “Maybe that’s kind of interesting.” My wife was the medical director for professional services while all this was happening and both us were early supporters of palliative care. When I got to be Dean, I dealt with palliative care on a regular basis. I told Bal that if palliative care was going to flourish, he would have to show that palliative care would save money. They published a paper in the mid to late 80s on the financial implications of palliative care that defended palliative care.
Q: How did you become involved with the Council of Palliative Care?
A: When Kappy Flanders, who Co-Chairs the Council with me, got interested in palliative care, we met and we agreed early on that a Chair in Palliative Care would be great for McGill, for our community and for the visibility of palliative care here and elsewhere. I think we at McGill had the first Chair in Palliative Care, certainly the first in Canada.
Q: Looking to the future, do you have any projects or adventures planned?
A: You know Sylvia and I are both 86. My wife and I do everything 50-50. We co-author everything and we always give co-presentations and will continue to do so.
As long as we are healthy and able to contribute,we would like to continue what we are doing. There are some extraordinary things happening with the medical school curriculum. There’s a mentorship program in the Faculty of Medicine called the Osler Fellowship. Six students stay with one faculty member for all four years. We would like to change the mandate of the Osler fellows so they become the people primarily responsible for tracing the development of student’s identities and following them. We always did this implicitly but now we are doing it explicitly, and we all believe that by doing it explicitly that we will do it better. The other thing about identity formation is that you don’t develop an identity in a straight line and periods of transition are difficult. McGill instituted a course for all medical students just before they go into their clerkship and just before they go into residency. We think we’ve got some new opportunities to nail this down but that’s going to take two or three years and I don’t think we can reasonably expect to keep working for much more than that, but as long as we are able and are permitted to, we will!