Medium ≠ Message

If you read one thing printed on real paper this week, make it this letter¹, followed by this response.²

(OK, you don’t actually have to print it on real paper, but know that it is, in fact, available printed on paper in the leading medical education journal. Or you can just point and click. For free.)

The rapid expansion of free, open-access medical edutainment has led us headlong into debate. To sum up the discussion, these two letters to the editor refer to a previously-published article by Mike Mallin, an emergency physician and EM educator in Utah, and colleagues surveying the use by EM residents of asynchronous education resources, which they define as “a student-centered modality of teaching which involves sharing online learning resources and promotes peer-to-peer interactions,” and which includes podcasts, blogs and other online shareable media.³ Known collectively/colloquially as FOAMed (Free Open-Access Meducation), these resources are now part and parcel of many EM training programs, able to be consumed at your own pace, on your own time.

Pescatore and colleagues, in their letter to the editor, worry aloud that the messages trumpeted via asynchronous resources are at risk of being interpreted as gospel truth by unsuspecting consumers without critical consideration of their merits. Particularly susceptible to this, they argue, are the most popular of these resources. They cite a discussion about treatment of infant bronchiolitis on an episode of the EM:RAP podcast wherein a popular contributor to that podcast made a treatment recommendation that is not supported by – and may be frankly frowned upon – by national societies in pediatrics (and which, in fact, may have been dangerous). If taken as truth rather than opinion – a real risk when impressionable listeners are swayed by the near-celebrities on popular sites – this may lead to an increase in an arguably unsafe practice.

Mallin and colleagues responded to this letter with the counter-argument that not only did EM:RAP address this concern, they did so in a timelier fashion than would have been possible through traditional academic channels (they point out in their rebuttal that the letters to the editor themselves were delayed by a year and a half from the time of the original Mallin article). The podcast in question was followed on in a subsequent episode by a lively debate on the merits of the initial recommendations, a deeper discussion of physiology, pharmacology and safety. It remains unknown if any infants were harmed in the interim.

I recall listening to the bronchiolitis episode of the EM:RAP podcast while driving and thinking, “that’s sort of a ballsy recommendation, given that it flies in the face of what I know.” I became more than a little bit indignant, in fact. What I didn’t do, was explore the bases of what I “knew” or what the podcaster “knew.” I didn’t go back to the literature to examine the claims made. I was a critic without thinking critically.

The popularity of asynchronous resources – EM:RAP being the prototypical example – should not be a surprise to any medical educator with their eyes and ears open, but the debate really comes about when it comes to the question of peer review and reliability of the information presented.

The old school would have you believe that, like the journals and textbooks of (almost) yore, before something’s printed on paper it should be vetted by a jury of its peers. This peer-review process – venerable as it is – is not without its own biases, but it’s been the standard of academic publishing for a century or more.

The up-and-comers will tell you, with equal vigor and conviction, that peer review is stodgy and slow, delaying and prolonging the knowledge translation cycle to the oft-quoted seventeen years, and limiting the dissemination of best practices. Peer review, they say, should come from the crowd-sourced responses to open-access publication of medical practices, procedures, research and opinion; the comments page provides immediate post-publication peer review of the most honest kind.

It’s a collision of new vs. old, but it’s more than that. It’s a debate about how best to share, how best to disseminate opinions and facts and practices, and how to debate these, vet these, and explore these within the academy and beyond.

I’m not here to take a side in the debate. In fact, I can see both sides, and perhaps I’ll take the middle ground, which is to say I think there’s a place for both sides. The danger of FOAM is that personality has the potential to trump substance – who says so becomes more important than what they say. Guess what, though? This applies to traditional literature as well. Because someone says so on EM:RAP does not make it so. But because someone says so in the New England Journal does not make it so, either.

The crucial ingredient is critical consumption. We must be thoughtful about what we consume. We must examine our beliefs, and those of others, incorporating into our own practice that which we’ve critically examined and believe to be useful, but we must be willing to part with those beliefs when new information become available. Traditional peer review, with its faults and biases, should be improved. Post-publication peer review – the “comments” section, if you will – should be respected and contributed to. Celebrity should not be equated with reliability. The medium – be it EM:RAP or the New England Journal – should not be the message.

1. Pescatore R, Salzman M, Cassidy-Smith T, Freeze B. The Benefits and Risks of Asynchronous Education. Acad Med. 2015;90(9):1183. doi:10.1097/ACM.0000000000000821.
2. Mallin M, Dawson M. In Reply to Pescatore et al. Acad Med. 2015;90(9):1183-1184. doi:10.1097/ACM.0000000000000832.
3. Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014;89(4):598-601. doi:10.1097/ACM.0000000000000170.

Relax, I’m a professional

There are days where I swear if I hear one more person talk about “professionalism” I might just vomit in my lap.

We’re all meant to be grading ourselves and our trainees and our colleagues on their professionalism, and yet this somehow gets boiled down to a 1-5 Likert scale, or a list of checkboxes to tally whether someone shows up to work on time or wears a nice enough tie or attends the required meetings or uses the appropriate titles when addressing colleagues.

What the hell are we on about here? What does it mean to display professionalism? Can we really identify a series of behaviors that, if all the boxes are ticked off and none of the prohibited behaviors witnessed, combine to make one a professional?

I’ll never forget what one great medical educator once taught a lecture hall full of my classmates:

“To be a professional means that part of who you are is defined by what you do.”

Now I’m a lot of things – among other things I’m a father and a husband, I’m a fan of the Montreal Canadiens, I’m an enjoyer of Willie Nelson’s earlier works, and I’m a doctor. Some of these things describe how I act (especially around Stanley Cup playoff time), but only the first and last define who I am.

You could create checklists of behaviors that I perform in relation to some of these attributes. You could count how many of Montreal’s televised games I watch (not nearly enough here in southern New England, where it’s all Boston Bruins all the time). You could check my recollection of the lyrics to all the songs on “Red Headed Stranger” (Don’t cross him, don’t boss him, he’s wild in his sorrow. Ridin’ and hidin’ his pain. Don’t fight him, don’t spite, just wait ‘til tomorrow. Maybe he’ll ride on again). My behaviors in these regards tell you something about what I am like, but they reveal only sparse hints as to who I am.

No list of actions can fully account for the most important characteristics – i.e. those by which I define myself.

How to choose which checkboxes for a physician and a professional? Clinical acumen? Bedside manner? Teaching of residents and students? Attender of meetings? Trying to condense professionalism into a list of discrete behaviors is about as effective as trying to define Shakespeare by listing his plays and sonnets.

But just defining myself by my work isn’t sufficient. There is something deeper about professional behavior – its intent and guiding principles that we’ve struggled to define. How can we measure – let alone teach – professionalism if we can’t even define its tenets in any meaningful way?

Howard Brody and David Doukas have taken us one step closer here. In an ethical analysis of what it means to behave professionally, they get at the deeper roots of professionalism, by examining the ethical underpinnings, the motives and social contracts that we profess to uphold (I use the word ‘profess’ with intent, as did Brody and Doukas, as a promise or a covenant – the verb being so much more powerful than the noun). They start with the premise that professionalism in medicine requires a commitment to the best interests of the patient over any other; upon that simple foundation, all else that defines professionalism is built. We in medicine have made a collective and public promise to put the needs of our patient above our own social or financial motivators. No easy task, this. But from this promise, Brody and Doukas contend, springs the trust of the patient and the trustworthiness of the physician.

Less clear to many in the field, though, is the second pillar of Brody and Doukas’ model of professionalism: professionalism as application of virtue to practice. Of greater importance than rote knowledge or technical skill – and in fact the value that makes each of these necessary – is virtue. By being virtuous – that is, doing the right thing at the right time for the right reasons (the right thing defined as that which promotes the patient’s interests at all times) – the physician displays the utmost professionalism.

The application of these two pillars of professionalism – the promise to the patient and the application of virtue to practice – come to bear in interesting and particular ways when it comes to the trainee in medicine. Students of medicine (which we should all consider ourselves, but in this case I refer to actual medical students and postgraduate trainees) model their behavior on those who mentor and teach them. We as teachers, then, owe it to our current patients, our trainees’ patients, and all future patients of our own and our learners’, to grab hold of this model of professionalism as the application of virtue, to hold true to this promise to put the patients’ needs above our own, and to model this behavior so that the tradition may be carried forth. Heady stuff, this.

One could argue that the well-being of current and future patients should be the motivator, then, for students, trainees and practicing physicians alike to learn hard, work hard, and study what we do – both as physician-scientists and educators – to best befit the needs of our patients, present and future. Duty hours, financial benefits, and dinner reservations should not be put ahead of the patient’s needs. We all could use a reminder of this now and again. We all could stand to benefit from this focus on promise and virtue.

Now I’ve strayed from my initial reaction to the professionalism meme, but I think these authors are onto something. By avoiding the concept of professionalism as a minimum base of behaviors – and worse, the characterization that these minimum behaviors are simple to achieve, and that only the basest few are incapable of improving upon them – in favor of professionalism as a virtuous ideal toward which professionals strive throughout our careers, through hard work and commitment to the patient’s interests, we can reframe how we define and teach professionalism.

Now I’m off to watch some hockey.