As the coordinator of the Professionalism courses in the Bachelor's program in Medicine, I was at the forefront of the implementation of this new theme within the AMC. In 2009, the professional development curriculum underwent its first formal assessment. Both students and teaching staff had to familiarize themselves with types of teaching that were unprecedented at the AMC. In order to facilitate this, we compiled a booklet (in Dutch) on the basic principles of this new curriculum. In it, we explain how professional conduct is a competency that can be learned. We also highlight how important it is that certain key characteristics and skills – including involvement and empathy – are not unlearned and discarded.
The approach to professionalism described in this booklet is similar to that of The Good Worker, in the sense that there is no such thing as a single model of a good doctor. Precisely because everyone is different, it is important for professionals to experience for themselves how to deal with the various situations that professional practice presents, we explain here. The idea of reflection not only entails having these experiences, but also consciously analyzing the effect the experience has on you and what you can learn from it.

Moral reflection

The teaching of professionalism fits in quite naturally with the subject of ethics. We tend to associate medical ethics with exceptional situations in medicine, or with dilemmas for which it is difficult to identify a satisfactory practical solution. However, situations that call for ethical consideration occur all the time in medical practice. This type of everyday ethics has increasingly become an important focus of my work. This focus has gradually shifted from contributions to political and other debates on issues of medical ethics, such as prenatal diagnosis and termination of pregnancies, to the way in which medical professionals can evaluate the morally sensitive side of their day-to-day work. To this end, I have explored various forms of moral reflection and developed several new methods myself (see Innovations in Education).  


The interface between ethics and professionalism is a fertile area for exploration. Although we may assume that ethical issues tend to be situations that professionals would prefer to avoid, research shows that it is precisely in these morally sensitive situations in contact with patients that doctors derive a sense of purpose from their work (Horowitz et al, Ann of Int Med, 2003, 772-76). This is hardly surprising: these are the situations in which, as a doctor, you can really make a difference on a personal level.
In my AMC teaching, I tried as far as possible to discuss ethical themes from practice as reflectively as possible. In other words, not to see them as issues that needed to be solved rapidly and set aside, but rather as a source of information, and potentially even of inspiration. The way in which you deal with morally sensitive issues as a professional can ultimately teach you a lot about what you consider to be of value. This forms the basis for Appreciative Moral Reflection.

Professional growth

This reflective approach to medical ethics can prove highly effective in facilitating professional growth. Medical professionals are increasingly affected by symptoms relating to burnout. This is not only caused by stress and fatigue, but also by a sense that one has insufficient opportunity to fully explore key aspects of one's own discipline. When teaching preceptors of the GP Vocational Training Institute, I used a variety of types of coaching support methods to them to discuss ethical issues with their GP trainees. These coaching sessions have a dual focus. The subject of the discussion is not limited to the moral views of the GP trainees: provided that the setting permits it, it also incorporates the preceptor's views. This means that the preceptors regularly explore issues at the heart of their own discipline, and their role as trainers facilitates this, which is something that many, especially more mature professionals need. These were some of the experiences and insights that resulted in the development of the course Training in Values.

Moral mindfulness

Focusing on professionalism can contribute to improved doctor-patient communication and therefore good patient care. If we see the medical professional as an instrument that is used, as it were, to care for the patient, the instrument must operate as flawlessly as possible. In order to do justice to the patient, any disruptive effects must be prevented. For example, we would expect a doctor to base the chosen medical treatment primarily on proven (evidence-based) effects rather than focusing too much on his or her own preferences. This applies equally well to the more personal and moral aspects of the care offered by doctors. Here too, we expect a certain objectivity in the sense that the doctor's personal preferences should not have a disruptive effect. This cannot happen unless he or she is actually aware of these personal preferences. Proper awareness of one's own moral standpoint ensures that there is no unconscious attempt to steer the consultation in a particular way. To describe the competency that allows you to discuss morally sensitive issues whilst also simultaneously taking account of one's own moral perspective, I coined the term moral mindfulness.

Professionalism, ethics and communication

As a competency, moral mindfulness is a type of reflection-in-action, involving both reflective and communication skills. Moral mindfulness can be relevant for medical professionals in a variety of settings: when discussing ethical questions with patients, with colleagues and with students. This chapter (in Dutch) describes how different forms of moral reflection and communication relate to each other in a medical setting and how they can feed off each other.
At a recent symposium on pediatric oncology, we discussed the link between moral reflection, moral counseling and moral discussion. The overriding conclusion was that skills training in moral reflection contributes both to improved patient care and professional growth.
At the International Research Center for Communication in Health Care (IRCCH), there is also a focus on the interface between professionalism, ethics and communication. During the International Roundtable (June 2013), I introduced the concept of moral mindfulness. In the Working Party ‘Strengthening Human Values in Healthcare’, one of our key focuses is the issue of how we can translate certain important values, such as those presented in the International Charter for Human Values in Healthcare into concrete skills in which professionals can be trained. I hope to apply my expertise during the coming years to meet this challenge, possibly working together with other IRCCH members.