Coulehan J, Williams P C
Department of Preventive Medicine, Helath Science Center, State University of New York at Stony Brook, 11794-8036, USA.
Acad Med. 2001 Jun;76(6):598-605. doi: 10.1097/00001888-200106000-00008.
North American physicians emerge from their medical training with a wide array of professional beliefs and values. Many are thoughtful and introspective. Many are devoted to patients' welfare. Some bring to their work a broad view of social responsibility. Nonetheless, the authors contend that North American medical education favors an explicit commitment to traditional values of doctoring-empathy, compassion, and altruism among them-and a tacit commitment to behaviors grounded in an ethic of detachment, self-interest, and objectivity. They further note that medical students and young physicians respond to this conflict in various ways. Some re-conceptualize themselves primarily as technicians and narrow their professional identities to an ethic of competence, thus adopting the tacit values and discarding the explicit professionalism. Others develop non-reflective professionalism, an implicit avowal that they best care for their patients by treating them as objects of technical services (medical care). Another group appears to be "immunized" against the tacit values, and thus they internalize and develop professional virtue. Certain personal characteristics of the student, such as gender, belief system, and non-medical commitments, probably play roles in "immunization," as do medical school features such as family medicine, communication skills courses, medical ethics, humanities, and social issues in medicine. To be effective, though, these features must be prominent and tightly integrated into the medical school curriculum. The locus of change in the culture of medicine has now shifted to ambulatory settings and the marketplace. It remains to be seen whether this move will lessen the disjunction between the explicit curriculum and the manifestly contradictory values of detachment and entitlement, and the belief that the patient's interest always coincides with the physician's interest.
北美医生在完成医学培训后，会形成一系列广泛的职业信念和价值观。许多人善于思考且内省。许多人致力于患者的福祉。一些人在工作中具有广泛的社会责任感。尽管如此，作者认为北美医学教育倾向于明确承诺遵循传统的行医价值观，其中包括同理心、同情心和利他主义，同时也默认遵循基于超脱、利己主义和客观性的职业道德的行为。他们进一步指出，医学生和年轻医生以各种方式应对这种冲突。一些人主要将自己重新概念化为技术人员，并将其职业身份缩小为一种胜任能力的职业道德，从而接受默认的价值观并摒弃明确的专业精神。另一些人则形成了非反思性的专业精神，这是一种隐含的宣称，即他们通过将患者视为技术服务（医疗护理）的对象来最好地照顾他们。另一组人似乎对默认价值观具有“免疫力”，因此他们内化并培养了职业美德。学生的某些个人特征，如性别、信仰体系和非医学承诺，可能在“免疫”过程中发挥作用，医学院的一些特征，如家庭医学、沟通技巧课程、医学伦理学、人文学科和医学中的社会问题也会如此。不过，要想有效，这些特征必须突出并紧密融入医学院课程。医学文化的变革场所现在已经转移到门诊环境和市场。这种转变是否会减少显性课程与明显矛盾的超脱和应得权利价值观之间的脱节，以及患者利益总是与医生利益一致的信念，还有待观察。
