Medical education’s authenticity problemBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2651 (Published 09 April 2014) Cite this as: BMJ 2014;348:g2651
- Brian W Powers, MD candidate1,
- Amol S Navathe, clinical fellow in medicine1,
- Sachin H Jain, lecturer, health care policy1
Medical education is punctuated by gating mechanisms, and anyone involved knows the unsavoury and contrived behaviors that this often breeds. At each stage of their training, aspiring physicians are pressured to shape and reshape their activities, interests, and values to meet the expectations of selection committees, attending physicians, and preceptors.
The notion of authenticity provides a useful framework for examining the impact of these dynamics on the development of new physicians. The term, popularized by Harvard Business School professor Bill George, entails discovering, understanding, and being faithful to your core values and purpose. Instead of emulating the characteristics, traits, or practices of others, authentic individuals interrogate their life experiences to discover their values and purpose through a process of continuous self reflection.1
Current dynamics in medical education are often at odds with authenticity. Selection requirements for undergraduate and graduate medical training lead aspiring physicians to appropriate and proclaim interests that are often disingenuous. Junior doctors hoping for selection into competitive training programs are pressured to research and publish, despite the fact that most will not pursue a career in academic medicine. In the United States, prospective medical students feel compelled to work in the laboratory or volunteer at a local hospital, whether or not they have a genuine desire to do so. Trial and error is an inherent component of career exploration, and students will inevitably find and lose interests along the way, but the current dynamics in medical education extend beyond this tendency. Within the current paradigm, physicians in training spend the formative years of their personal and professional development—nearly two decades—emulating others and conforming to expectations, often at the expense of discovering their true values, motivations, and purpose.
The challenge of authenticity extends beyond selection processes, permeating the curriculums within which medical students and junior doctors train. Movements towards standardized learning and assessment often leave little room for reflection, introspection, and self discovery. This is particularly glaring in attempts to standardize communication skills—the heart of the patient encounter. At various points in our training, we were taught specific language, behaviors, actions, and reactions to use when interacting with patients. This focus on product, not process, can result in physicians being perceived as stiff, scripted, or even fake. As an example, earlier this year one of us (BWP) witnessed a first year medical student who, when hearing that a patient recently lost a leg, asked: “was the amputation hard for you?” The woman quipped back “well, they cut my leg off.” Normally charming and affable, the student’s natural communication style was stymied by trying to conform to the standards outlined in his education. Instead of focusing on emulating best practices, curricular efforts should help students develop an authentic, genuine style of practice consistent with their personality and character. Empathy and humanism flow from authenticity.
It is worth noting that efforts to counteract these trends have increased. In the US, the Association of American Medical Colleges’ holistic review project is working to promote a more comprehensive and individualized assessment of medical school applicants and their character.2 Increased commitment to rating students by the depth of their interests and achievements, rather than by their engagement with specific activities, will help build a culture of self discovery and authenticity among prospective medical students. It should draw passionate people with diverse interests into the profession. Furthermore, medical education bodies across health systems continue to refine their expectations for undergraduate training, increasing the focus on the humanistic dimensions of medicine and the importance of self reflection.3 4
But medical schools and training programs implementing these reforms face an inherent paradox: reorienting around authenticity requires standardizing experiences and defining authenticity. With formalized requirements and expectations in place, gamesmanship and emulation will remain. Despite this inevitable tension, we believe that authenticity must assume a more prominent position among our educational priorities. According to Fish and de Cossart, teaching and assessment need to focus “not only the professional’s visible behaviour, but also the motivations that drive . . . the practitioner’s underlying humanity and self-knowledge.”5
Promoting and preserving authenticity will be difficult; there is no simple rubric to assess authenticity, nor a specific curriculum to teach it. But this should not detract from its importance as a core value in both medical education and medical practice. Evidence suggests that a workforce of authentic physicians can yield improvements across the spectrum of care. Self awareness and reflection—hallmarks of authenticity—are strongly correlated with resilience to burnout among physicians.6 An authentic workforce can also improve the performance of clinical teams. A study of nurses found that authenticity led to greater trust, engagement among workers, perceived quality of care, and willingness to voice concerns.7 Finally, authentic people excel at building strong genuine relationships that motivate, inspire, and empower those around them8—traits that can help physicians form strong therapeutic relationships with their patients.
To capture this potential, it is crucial to understand the importance of authenticity, and the current structural, policy, payment, and managerial dynamics that go against it. As global efforts at reform progress, we hope to see authenticity assume a place alongside patient centred care, practice based learning, and system based practice as essential priorities for medical education and medical practice. In a profession built on empathy and compassion, why we do what we do, and who we are, are often just as important as what we do.
Cite this as: BMJ 2014;348:g2651
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.