As depicted in Figure 1, a total of 811 papers were evaluated, with subsequent Abstract full text search analysis identifying 25 papers deemed relevant in two of the three domains, and 8 papers had all three factors under consideration. The factor that was most often missing was evidence of an implemented curriculum — we have indicated in bold on our Resultant Publication list those 8 papers containing all three factors. Our practical decision to conduct detailed analysis of all 25 papers was based on the relative lack of articles containing all three factors, and it was noted that 17 articles lacking an implemented curriculum either proposed a curriculum or argued for curricular change.
The distinctive quality of these eight papers is that each lays a foundation of the conceptual framework of either virtue or care ethics and builds upon that basis with a curriculum that identifies humanistic outcomes. These papers emphasize multiple venues for virtue or care ethics — in undergraduate and graduate medical education, as well as in faculty development promoting mentorship — and as such, provide instructive templates towards future curricular development in this area.
The 25 articles range in date from 1994 to 2017, starting in proximity to when Gold Humanism efforts to foster humanism began and flourished, and when professionalism as a competency was introduced in US medical education assessment with one publication cluster noted in 2005-2009, and another cluster in 2015-2016. The journal Academic Medicine had the largest number of publications, with the Journal of Medical Ethics following, and then a distribution between other medical ethics and health service journals and publishing houses. We next proceeded to identify relevant themes.
Themes
DD and NS developed a draft set of themes that were evident from the 25 papers cited, which were subsequently refined with JdG and BC, with a resultant nine distinctive themes and four side issues in these papers (Table 1). These themes were: Altruism, Development of Virtuous Traits, Relationships, Dissonance/Virtue versus Principlism, Care as a Virtue, Praxis in Humanistic Behavior, Role Modeling, Pedagogy, and The Culture of Medicine/The Hidden Curriculum. Additionally, there were four significant Noteworthy Considerations that were identified and were coherent but not centrally on point as a theme of cultivating virtue/care ethics and humanistic behavior (Table 2). These considerations consisted of Professionalism/Professional Formation, Narrative, the Use of Learning Communities, and the Need to Prevent Burnout.
The themes of Altruism, Development of Virtuous Traits, and Care as a Virtue are all related to the development of character in ethics within the educational process. The Altruism papers concentrated on perspectives that altruism is a prevailing virtue in medicine, often linked to the caring enterprise of healing (Brody & Doukas, 2014). Altruism was posited as running deeply such that this personal virtue can also be institutional, uniting the ideals of professional behavior (Schaechter & Canning, 1994). Some propose that communities of learning should be cultivated, focusing on altruism to encourage humanism (McCammon & Brody, 2012). Altruism was also considered a key virtue to counter negative influences in medical culture (discussed below) (Coulehan, 2005) Altruism also conceptually questioned: Can and should giving of oneself be so great as to allow self-sacrifice? (McCammon & Brody, 2012).
The Development of Virtuous Traits theme appeared most commonly in our analysis, focusing on how virtue integrates health care values into the practice of medicine through a social contract (Brody & Doukas, 2014). The virtues that are encouraged within the profession of medicine allow for their teaching to its learners promoting professional conduct and healing (Doukas, 2003). Virtue and care ethics within medical education identify those aspects of character central to patient care and have been encouraged among medical learners (McCammon & Brody, 2012). Understanding virtue ethics may assist learners in better understanding ethical issues in healthcare, and thereby support development of humanistic behavior (Schaechter & Canning, 1994). Virtue and care ethics helps the learner to utilize “internalized values,” and incorporates emotion with cognition and complements other ethics teaching (Coulehan & Williams, 2001). Promoting virtue calls for sound role-modeling by educators (Coulehan, 2005).
The Care as a Virtue theme addresses the concept of caring as being an augmenting factor to virtue ethics by incorporating emotion (Benner, 1997). With this perspective, care helps to reveal the type of humanistic practices that learners might strive for, and how education should focus on caring to amplify the healing process (Benner, 1997). The relationship of care to medicine is thought to be conveyed by way of love, connection, and caring through empathy (Madani, 2017). Being a caring person was cited as an important attribute of highly influential educators of clinicians (Osterberg et al., 2015). Often, care was coupled with other virtues such as altruism, compassion, and empathy in its explication in promoting humanism (Kotzee & Ignatowicz, 2016).
The theme of Dissonance/Virtue versus Principle describes how traditional deontological and consequentialist approaches to ethics in medical school can conflict with virtue and care ethics frameworks in such a way that they may seem to ignore or overlook the value of character or caring relationships among those with unequal power within medical ethics (Doukas, 2003). Some call for a need to segregate the teaching of principles in medical ethics from aspects of virtue and care ethics (Coulehan, 2005). Concepts of care and character are very different in the minds of students than the notion of duties and obligations (Coulehan, & Williams, 2001). Virtue ethics focuses on how character promotes traits that allow a person to be a better healer whereas respect for autonomy is concerned with what one owes to another person as a right (Doukas, 2003). Some argue that this perspective of character is a better means for analyzing ethical issues and healthcare than Principlism, leading to better acquisition of humanistic behavior (Kotzee & Ignatowicz, 2016). The complementary nature of these teachings to one another is cited to augment each other (Madani, 2017). It has been suggested that learners ought to be taught how to identify and clarify the differences between rules and character (Leffel, 2015).
The themes of Pedagogy and Role Modeling describe how the learner needs to be familiarized with virtue and care ethics in healing with both knowledge and learning through observing. With the Pedagogy theme, some papers focus on the educational modalities such as utilizing virtues (specifically relating to roles) in ethical cases to improve understanding (McDougall, 2013). Some are specific on how to teach virtue ethics with extrapolations from nonmedical school environments to healthcare (Gould, 2002). As noted previously, some believe that teaching by way of virtue ethics is better than that utilizing Principlism, and the former ought to be part of the medical curriculum (Kotzee & Ignatowicz, 2016). This advocacy includes utilizing digital technologies to teach virtue ethics in healthcare environments (Bolsin, 2005). Another suggested utilizing teaching strategies using care ethics to shift the focus from inner qualities to relational capacities, incorporating emotions and reason, promoting humanistic healing (Benner, 1997). With the Role Modeling Theme, papers emphasized the essential aspect of role modelling to promote virtue and care ethics. To enhance virtue, improved role models are needed as well as literature that promotes examples of role models (Coulehan, 2005). Narratives can help improve understanding of caring role modelling (Osterberg et al., 2015).
The theme of Relationships describes how virtue/care ethics are based upon the character-based interaction of two or more persons, although care ethics emphasizes the inequality of the relationship-based interaction. This theme notes how relationships foster care in medicine through humanistic practice in the caring endeavor (Madani, 2017). Each practitioner needs to acknowledge these aspects of character, aspire to enhance, or augment them within oneself, and promote the betterment of the patient (Benner, 1997). Virtue and care may effectively be engaged through relationships not only with patients but also with their families to enhance compassion (Schaechter & Canning, 1994). Patient-centered care implicitly requires a caring attitude towards patients. The role modeling relationship with teachers is thought to support this ethic (Branch et al., 2009; Coulehan, 2005). Humanistic teachers are influential in imparting care to their learners, and learners are drawn to them as role models of empathy and interpersonal communication (Branch et al., 2009). Mentorship enhances care beyond one’s medical training (Wald et al., 2015). The relational nature of caring also emphasizes interpersonal aspects of emotion and competency (Benner, 1997). Educational opportunities are recommended to promote humanism and professionalism to address challenging relationships with patients (Coulehan, 2005).
The theme of Praxis/Humanistic Behavior concerns the ways in which the learner may come to manifest humanistic behavior when incorporating the needed virtues and care in healing. Virtue and care ethics act as a foundation to humanistic behavior and professionalism in patient care, promoting practice care particularly when achieved with clearly articulated objectives (Benner, 1997). Outcomes include clarification of values and diversity of values and personal growth, promotion of caring attitudes, meaningfulness of professionalism, and growth as endpoints of value (Branch et al., 2009; Kopelman, 1999). The types of identified humanistic behavior in these 25 papers included: virtues of compassion, altruism, and self-awareness, and role-modeling by medical educators. These articles included such endpoints to evaluate humanism and professional identity formation as visual narratives that convey humanistic insights (Arnold et al., 2016), Humanistic Practices Teaching Effectiveness Questionnaire (Branch et al., 2009), narrative-based professionalism portfolios (Coulehan, 2007), moral reasoning assignments (Irby & Hamstra, 2016), experience sampling methodology (Kotzee & Ignatowicz, 2016), how people act in experimental settings (Kotzee & Ignatowicz, 2016), and e-portfolios (Wald et al., 2015). Other outcome attributes such as mindfulness, exceptional communication skills, and passion for care were also cited (Wald et al., 2015). Additionally, there was a focus on how virtues such as compassion can be nurtured and thereby enhance the educational process and facilitate humanistic care to patients and their families. (Schaechter & Canning, 1994)
The theme of Culture/Hidden Curriculum addresses how deleterious aspects of medical culture (through damaging moral conduct and toxic character) can upend humanistic educational efforts (Coulehan & Williams, 2001). This theme describes the challenges of an adverse culture that can be hostile to virtue and care ethics. Medical training can be seen as a negative reinforcer of empathetic virtue (Brody & Doukas, 2014). As a result, there can be a noteworthy gap between the virtuous physician one aspires to be and the physician that one is, requiring that we incorporate aspects of pedagogy and role modeling to improve professional identity formation in recognizing the need for cultural change (Coulehan, 2005). There can be many challenges in promoting virtue and care ethics given that we are human, so we must address the moral distress that occurs when we fall short of our aspirations (McCammon & Brody, 2012).
The identified noteworthy considerations of professionalism, narrative, burnout prevention, and learning communities, can be interpreted as additional means to counter impediments that adversely influence the cultivation of humanistic behavior. Professionalism is relevant in this scoping review as the aspirational intent of virtue and care ethics is professional development to overcome the detractive aspects of medical education that negatively affect behavior. Professionalism is cited by many papers as an application of virtue ethics to the medical social contract, based on altruism and contract keeping (Brody & Doukas, 2014). Reflective exercises have been utilized to promote care and caring, resilience and wellness with the goal of becoming humanistic physicians (Wald et al., 2015). Virtue ethics is seen as not only a basis for professionalism but also a means to professional formation (Coulehan, 2005). Virtue ethics is also seen as a means by which to foster ethical and professional educators (Doukas, 2003). The relationship between virtue ethics and professionalism helps to guide the learner highlighting the aspirations of character towards one’s own moral development (McCammon & Brody, 2012). As there is an educational requirement for professionalism, cultivating appropriate virtue and care ethics promotes patient care (Doukas, 2003). One paper cites “professional responsibility” as a virtue, playing a central role in the development of medical professionalism (Barilan, 2009). Compassionate care and professional identity that is respectful of patients promotes humanism, which is vital to the professionalism enterprise (Coulehan, 2005).
The consideration of Narrative described the modality of teaching using narratives on physician virtues, motivations, and behavior looking at literature (rather than physician-life stories) to encourage compassion (Coulehan, 2007). Others advocate personal medical narratives to enhance humanistic care (Arnold et al., 2016), using stories told from the perspective of physicians and then applying a virtue framework to better understand the ethical aspects of character (Toon, 2007). Narrative-based professionalism efforts are intended to promote integrity, empathy, and patient engagement while promoting compassionate and responsive professional identity (Coulehan, 2005). Personal narrative as a reflective writing exercise has been used to enhance student resilience and improve mindfulness (Wald et al., 2015). Another avenue of narrative has been the use of appreciation inquiry in writing narratives about influential teachers to promote excellence, self-awareness, encouragement, and role modeling (Osterberg et al., 2015).
The consideration of Prevention of Burnout specifically focuses on burnout prevention by focusing on relationships with patients, open discussions on burnout, and the challenges of suffering patients (Kesselheim et al, 2015). Learning Communities have been utilized to enhance role modelling of humanism and conveying caring attitudes as part of faculty development across several medical schools (Branch et al., 2009). That utility includes requisite faculty development to enhance mindfulness, humanism, and communication skills, as well as to concentrate on reflective learning in groups and enhance skill building and role modeling (Osterberg et al., 2015). With medical students, efforts to foster altruism and compassion can enhance care and humanism toward patients (Schaechter & Canning, 1994).
When the articles were evaluated for relevant metaphors (Table 3), these clustered into two domains: Aspirational and Detractive. The Aspirational metaphors consisted of care and virtue being “Habits of the heart,” (Irby & Hamstra, 2016), that virtue was like “A beacon on a map,” (McCammon & Brody, 2012) and that one needed to push oneself as if “Learning to drive on the edge of the tires” (Benner, 1997). The Detractive metaphors consisted of how physicians can see themselves versus others as “Heroes vs. Villains,” that physicians believe that they are in an “Ailing culture” and that narrative can assist in exploring the “gap between virtue and what we do” (Coulehan, 2007). The utilization of ethics can be seen as a “Bludgeon,” (Brody & Doukas, 2014) and that the journey of becoming and being a physician can be one of “Medical Monasticism” (i.e., self-sacrifice) (McCammon & Brody, 2012). This analysis shows a deep tension in the literature on virtue and care ethics education. These thematic and metaphorical elements of the articles that we reviewed lend support to the idea, discussed below, that within the medical curriculum the efficacy of (and desire for) virtue and/or care ethics education is significantly tempered by systemic issues (especially mastery of medical information and procedures), which could hinder virtue development and role-modeling.
