Abstract
The Philadelphia College of Osteopathic Medicine has developed an exercise to introduce professional ethics and behavior at the earliest stages of medical education. During orientation, each incoming class creates a class vision statement. After small group discussions on professional ethics, honesty, and responsibilities, representatives from each group collated student input and constructed a class vision statement reflective of student consensus on these issues. Each vision statement was recited as an oath during the white coat ceremony at the conclusion of the orientation program. Despite the fact that previous vision statements were unavailable to each incoming class, there were many commonalities among the statements created.
Central elements of all vision statements include commitment to altruism, compassionate treatment of patients, and honesty and integrity in all professional interactions. Humility, the capacity to recognize and accept one's limitations in knowledge and skills, was also a key element in each statement. Three of four statements specifically recognized the teamwork and mutual respect that should be engendered among all members of the health care team. Each vision statement had prominent statements regarding the learning process during osteopathic medical school and acknowledged the importance of active and lifelong learning in the students' career paths.
Student evaluation of this exercise has been positive, especially the recitation of the statement during the white coat ceremony. Results suggest that the development of a class vision statement represents a powerful mechanism for addressing the importance of professional attitudes, behaviors, and ethics at the earliest stages of medical education.
The Medical School Objectives Project has identified four attributes that physicians must demonstrate to be effective in the practice of medicine in the 21st century: altruism, skill, knowledge, and duty.
1 Teaching the skills and knowledge required of a practicing physician is traditionally achieved through didactic courses in the first 2 years of medical school, the more clinically oriented clerkships in the final 2 years of medical school and during internship and residency training programs. However, instilling attributes such as duty and altruism, as well as developing professional behaviors and attitudes during medical training, poses a greater challenge to medical educators.
2-4 Traditionally, these elements of the “hidden curriculum” are taught by the example of peers, residents, and attending physicians in the clinical setting.
2
To underscore the fundamental importance of these attributes for the development of a competent and caring physician, many institutions have incorporated exercises into the first-year medical curriculum that focus on these issues. Often, professional attitudes and behaviors are addressed in case-based small group discussions or other didactic exercises as part of medical ethics and clinical medicine courses.
4,5 We and others
6,7 have chosen to introduce these professional attitudes and behaviors as early as possible in medical training with the development of a class policy or vision statement during orientation that is recited during the white coat ceremony as a promise or oath.
The classes of 2003 and 2004 were assigned readings focusing on professional issues to be completed during the summer preceding the first academic term. For the class of 2003, students were assigned articles by Selzer and Charon,
8 Howell,
9 Connelly,
10 Novell,
11 and Shelton.
12 These readings focused on humanism, virtue, and mindfulness for physicians. For the class of 2004, the assigned readings by Branch,
13 Minogue,
14 Carson,
15 and Swick
16 focused on medical ethics and issues of professionalism. The classes of 2005 and 2006 did not have assigned summer reading before matriculation.
At orientation, each class was instructed to develop a class policy or vision statement. These were described to the students as “promises” that they would make to themselves, their classmates, the faculty, and their future patients, as well as the other health care workers with whom they will interact as students or future physicians. They were also instructed that these promises were to focus on the type of medical students and future physicians the students would strive to become. Each class was presented the following question designed to help them collect their thoughts and frame their discussion:
Presentation of the question was followed by suggestions to help the groups focus their discussions. Suggested areas of discussion included ethics and honesty between classmates and with faculty, responsibilities to patients and their “stories,” cultural diversity, and impact of medical economics, medical ethics, and privacy issues on the practice of medicine. Finally, each class was asked to think of promises that they would make to their families and loved ones, their community, and to themselves.
Involved faculty members were available to the students as facilitators and advisors. It is interesting to note that students chose not to seek faculty advice at this phase of the process. Each class was divided into 20 groups of approximately 12 students who discussed their thoughts over lunch. The appointment of a “scribe” was suggested to collate each group's thoughts. Groups were instructed to formulate statements that reflected the group's consensus and to appoint a representative.
Representatives from each group met with key faculty members for dinner that evening or breakfast the next morning. The thoughts from each group were coalesced into a class vision statement at this meeting. The representatives' summaries were entered via computer onto an overhead projection system so that each representative could see the document as it was being constructed. When the final version had been prepared, the student representatives reported back to the class as a whole about the process, the themes that emerged during the discussions, etc. The class vision statement was then read by the class, led by the dean of the college, as an oath before the white coat ceremony.
The vision statements created by the Philadelphia College of Osteopathic Medicine classes of 2003, 2004, 2005, and 2006 are shown in
Figures 1,
2,
3,
4, respectively. As a result of our initial experience with construction of a class vision statement, we made slight modifications to the process during the next 3 years. For example, the vision statement created by the class of 2003 (the first class to experience this exercise) was the longest. This was due to our desire to let all the voices that emerged be heard and a reluctance to “edit” students' thoughts. However, because of its length, the vision statement created by this class was cumbersome when read by the class during the white coat ceremony. As a result, during the construction of vision statements by representatives of subsequent classes, we suggested that students be mindful of the final statement length, to be concise, and to avoid redundancy. Subsequent statements prepared by the classes of 2004, 2005, and 2006 were shorter.
Construction of the entire statement by all 20 class representatives also proved to be cumbersome. Therefore, for construction of the vision statements for the classes of 2005 and 2006, the class representatives met initially and collated each group's summary. During these preliminary discussions, several recurring themes were identified. Once these themes were established, the group was divided into subcommittees to craft the portion of the statement corresponding to that theme. This theme-based organization of the vision statement is particularly evident in the statement constructed by the class of 2006, which was organized around attributes that the class sought to embody. Statements made by previous classes were organized around promises made to particular groups (eg, themselves, patients, faculty) as is typified by the vision statement created by the class of 2003.
Despite the fact that previous vision statements were intentionally not made available to each incoming class, there were many commonalities among the four statements created thus far. Altruism, one of the attributes identified by the Medical School Objectives Project as necessary to meet society's expectations of physicians, was a common theme. A commitment to the empathetic and compassionate treatment of patients was also a central element. Respect for the privacy and/or dignity of patients was explicitly promised in three statements. The need for honesty and integrity in all interactions was an integral part of each vision statement, as was humility, the capacity to recognize and accept one's limitations in knowledge and skills. Three statements recognized the teamwork and mutual respect that should be engendered among all members of the health care team.
All vision statements had prominent statements regarding the learning process during medical school and acknowledged the importance of active and lifelong learning in their chosen career paths. For example, the class of 2003 promised to “take responsibility for our education” and to “be active learners.” The class of 2004 promised to “establish a partnership for learning with our teachers based on mutual respect, responsibility, and understanding.” The class of 2005 committed to “strive to reflect [faculty's] commitment to teaching through our commitment to learning. We promise to be lifelong learners.” The class of 2006 vision statement promised to “give our all to our faculty, as the beneficiaries of their knowledge and willingness to lead us.”
A surprising common thread in our class vision statements was a commitment to balance personal/family and professional responsibilities. The class of 2003 vowed to “maintain a balance between our physical, emotional, spiritual, and social well-being.” The class of 2005 stated, “We owe it to ourselves and those around us to maintain a healthy mental, physical, and spiritual balance in our lives.” The vision statement for the class of 2006 promised to “...remember the support our family and friends lend to our achievements. If we respect all of these aspects during our education and professional careers, we will maintain a precious balance in and perspective on life.”
Students from the class of 2003 were asked to evaluate the exercise following completion of the orientation program. On a scale of 1 (worst) to 5 (best), students were asked to evaluate individual elements of the orientation program, including the development of the class vision statement. The value of creating a class vision statement was rated highly by responding students (average score, 4.51). The question that formed the springboard for discussion was also rated strongly (average score, 4.18). The white coat ceremony received positive marks from the students (average score, 4.7). As part of the ceremony, the presentation of the class vision statement also received high marks (average score, 4.32). Weaker elements of the vision statement exercise included the faculty introduction of the assignment (average score, 3.86) and the representative student reports to the class regarding the construction of the statement (average score, 3.78).
The impact of these exercises on the development of professional behaviors over the continuum of undergraduate medical education remains speculative. For example, it is difficult to ascertain whether the promises relating to the empathetic treatment of patients made during recitation of the vision statement translated to more positive professional interactions with patients. Whether these exercises influenced student attitudes during their undergraduate medical education, internship, and residency training may be easier to address. We plan to assess whether the vision statement impacted the development of professional attitudes for all classes at the end of the 2003–2004 academic year by a survey instrument. At this time, the class of 2006 will have completed their second didactic year and will be preparing for the Comprehensive Osteopathic Medical Licensing Examination (COMLEX–USA) Level 1 and the beginning of clinical rotations; the class of 2005 will have completed the first year of clinical rotations; the class of 2004 will be graduating; and the class of 2003 will be completing their internship year. This format will allow us to assess about 1000 students who have experienced the construction of a class vision statement during orientation at various later stages of training.
The Philadelphia College of Osteopathic Medicine has developed an exercise for incoming medical students to introduce professional ethics and behavior during the orientation process. Each incoming class creates a class vision statement that is recited as an oath during the white coat ceremony. Commonalities in the vision statements created thus far include commitment to altruism, compassion, honesty, and humility. Student evaluation of this exercise has been positive, especially the recitation of the statement during the white coat ceremony. Our results suggest that the development of a class vision statement represents a powerful mechanism of addressing the importance of professional attitudes, behaviors, and ethics at the earliest stages of medical education.