iStock/David Ahn

September 25, 2012 | Medical students may be drawn to the profession by a sense of idealism and altruism, but all too often they begin to lose that outlook in their third year of medical school, Dr. David Hirsh said.

Hirsh is the director and co-founder of an innovative program that seeks to combat the phenomenon -- known as “ethical erosion” -- by creating a new educational model.

In the third year of training, medical students typically do monthlong rotations, in which they quickly move among different disciplines. But students in Harvard Medical School’s Cambridge Integrated Clerkship are assigned to teams that follow patients through diagnosis and treatment and even after they’re discharged from the hospital.

As a result, students learn to be empathetic and patient-centered.

“It’s a relationship-based model of learning where duty and commitment imbue the learning process, the learner and the teacher,” Hirsh said.

Hirsh spoke with Faith & Leadership about how efforts to remake the medical school experience have gained acceptance and delivered some unexpected benefits for students, teachers and patients. The following is an edited transcript.

Q: How did you reach the conclusion that you needed a better way of forming and training medical students?

There are three important missions when you are trying to help a person become a physician/caregiver. One is knowledge, one is skillfulness, and the other might go under the rubric of professionalism.

Some people would boil professionalism down to altruism and duty. There are others who have a much broader rubric for professionalism. Some would say professionalism is in essence just humanism, professionally applied.

Medical schools have been traditionally quite excellent at helping students learn the knowledge part and the skill part, across a wide variety of skills.

Medical schools traditionally have not used deliberate training for professionalism. They’ve relied on bringing in wonderful people and having them do wonderful things, and hoping professionalism takes care of itself.

But in the last couple of decades, there has been a real movement internationally for professionalism. We knew that it was underlying the way the world was thinking about medical education, so what we brought to it was the hope that we could be very direct in our efforts to foster humanism.

We wanted to see if we could deliberately design the structures of education to foster the things that we thought of as being valuable. And those things were well-described in this rubric of knowledge, skills and professional demeanor.

Q: What are the core values that drive this program?

An article in the New England Journal of Medicine was first written as our philosophy piece. We called the article “‘Continuity’ as an organizing principle.”

The continuity is between student and patient, between student and faculty person, between and among students. They would develop a community orientation toward this very service-oriented profession, not “it’s all about me.”

The patient needs to matter to the student. The student should be longitudinally connected to that patient with an authentic role in care.

There’s also continuity between the student and content. They get to revisit and reflect upon the material again and again. So the educational environment itself is continuous, because the curriculum is spiraling. Students are re-engaging the themes at a higher level, being allowed to learn, forget and learn anew.

Expertise literature speaks about the capacity to be the ever-novice, never content with what you might know.

It’s a relationship-based model of learning, where duty and commitment imbue the learning process, the learner and the teacher. There’s continuity of the curriculum where they can revisit and be frail, where not knowing is OK.

It’s the seeking to know anew with a developmentally rational trajectory, where people are nourished by the processes of learning rather than the outcome. The outcomes must be revisited again and again. So that’s the third continuity.

The continuity of peer/peer is something we actually didn’t come upon until later, but it makes sense, of course.

And then, finally, we had a fourth continuity: the continuity of idealism. And that is if you enter medical school idealistic, you should exit at least that much, or more, idealistic. That would be the counterweight to ethical erosion.

It’s not about us as individuals. It’s about relieving human suffering.

Q: Why were you motivated to create this program? How did that come about?

A lot of us experience things in medical school or in our medical training that make us think hard about why we are doing this -- what is the core principle? And what are the values that led to this?

Some things are curricular. Some things are just in the surround, in what they call the hidden curriculum. And as you have those reflective moments, it generates imagination of what education ought to be or might be.

As it turns out, much of what is residing in the hearts of all of us is also well-described in the literature. There is a type of literature that has been around since about 1994 that addresses something called “ethical erosion.”

The articles are oftentimes really quite sternly entitled, written with language that is quite crisp, I would say. One title is “Is there a hardening of the heart during medical school?”

Another one, more of a thought piece than a study, is called “Vanquishing virtue.” So there are lots of very powerful writings about ethical erosion.

We find it far beneath the highest ideals of service professions, and obviously way far behind the ideals of the sacred traditions of medicine, where service to your patient and using science to relieve human suffering are the utmost sacred.

If we’re going to have to meet that standard, it can’t be left to chance alone. We have to work hard deliberately and make curricula to do that, to bring that out, to foster and nourish it.