As a southerner, I really like colorful expressions. “That dog won’t hunt” is one that I use when I am hanging with my Yankee friends and I want them to give me a “what is he talking about” look. “I wouldn’t know him from Adam’s off ox” is one that I love but I find I have to explain it way too often as I am not usually hanging with people familiar with oxen team terminology. One that I find more useful as I get older is “lipstick on a pig” as in “That’s just putting lipstick on a pig.” The expression, per Wikipedia, describes “making superficial or cosmetic changes in a futile attempt to disguise the true nature of a product.”

The medical education process seems to have taken a “lipstick on a pig” approach to reform. I have written about what people want in a doctor before (found here) and here is WebMD’s list from an article in the Mayo Clinic Proceedings:

Traits listed by the patients, along with the patients’ definitions of those traits:

  • Confident: “The doctor’s confidence gives me confidence.”
  • Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
  • Humane: “The doctor is caring, compassionate, and kind.”
  • Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
  • Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
  • Respectful: “The doctor takes my input seriously and works with me.”
  • Thorough: “The doctor is conscientious and persistent.”

Contrast that with the criteria for selection for medical school (grades and scores on a single standardized test) and the criteria for selection for residency training (grades and scores on a series of 2 standardized tests). It is my experience that test scores often don’t correlate with the things patients want in a doctor.

Recently, post-medical school training has attempted to emphasize qualities other than test-taking skills. The ACGME Outcomes Project, for example, has been in effect for 14 years and requires residencies providing post-medical school training to measure growth in characteristics such as those listed above. Efforts to change the medical student curriculum, though emphasizing the behavioral buzzwords found in the WebMD article, continue to have an assessment component focused using multiple choice type questions. Growth as a person is subordinated to acquiring knowledge for assessment via multiple choice testing, rendering the curriculum change efforts “lipstick on a pig.”

I have focused most of my career attempting to mold learners in their post-medical school years and have found that attitudes are set. Where residents come into the program from medical school regarding their attitudes towards patients is where they tend to stay. I was excited to recently come across this article, implying that it may be our educational efforts in the early training years that are lacking, not the learners’ ability to change. The authors suggest that the learners’ ability to store and regurgitate knowledge (IQ) was fixed, but their ability to incorporate professional values such as compassion and integrity (EQ) is fluid. To accomplish changes in behaviors and attitudes is going to mean not applying more lipstick but getting rid of a lot of the pig. Picking “listen to the patient” from a multiple choice answer list will no longer be a sufficient assessment. Assessing the learner at baseline (even prior to admission), establishing a set of non-negotiable standards, measuring behaviors using Standardized Patients as well as real patient encounters on multiple levels, using peer evaluations to capture attitudes not observed in formal settings, and forcing reflection on the part of the learner with the learner at risk of failure for not performing up to par will be necessary to effect these changes. It will mean changes in the training milieu as well. No more “Butt Boxes,” lists of words mispronounced by illiterate patients, comments about patients’ lack of “personal responsibility” to justify providing substandard care, or other activities that belittle or dehumanize patients in public or (more insidiously) private.

The authors suggest that establishing a strict standard and enforcing a “zero tolerance” for learners and faculty are necessary to drive this type of reform. I can only wonder if we can meet this standard or if we will quickly run out of faculty and students while trying to do so.

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