From the Educational Trenches: It's all about Habit Formation

By Rob Houtepen (HES)

Rob is responsible for the program in clinical ethics and health law in year 3, 4 and 5 of the Maastricht Medical School (r.houtepen@mastrichtuniversity.nl).

The discourse about teaching and end terms is usually framed in terms of knowledge, competencies, behavior and attitude. Thus, medical ethics teaching is supposed to account for itself in those terms: aiming always for comprehensible rationality, preferably for practical utility and arguably for sufficient empathy. But the universal experience from ethics teaching in medical schools is that:

1. Except in dramatic cases, it’s hard to attract and keep attention from these very intelligent and motivated, but practically minded and not too reflective students.
2. Ethics is perceived by the students at most as a worthwhile addition to the core of medicine, rather than part of such core
3. It’s realistic to be skeptical about the manner and degree to which ethics will function in practice as the desired (self) reflective critical component of a practice that is dominated by stimuli to achieve a high turnover of sufficiently satisfied patients. These stimuli are both administered by the system as a whole and by the current doctors working in it.

Reading the excellent study by Yolanda Witman (2008) on medical leadership convinced me that those problems can only be addressed sufficiently by introducing the concept of the ‘medical habitus’. It reminded me that the so called ‘hidden curriculum’ in medical education is as powerful today as it has always been. The standard initial student motivation is ‘helping people by solving their medical problems’. As long as they do not feel themselves sufficiently competent in medical problem solving, they are not really open to any messages that might detract them from this pursuit. In fact, anything outside the paradigmatic patient coming to the doctor for a ‘real’ (i.e. clearly somatic) medical problem (“What can I do for you now within the limits of my possibilities?”) usually fails to draw their attention anyhow: so much for prevention, care and social aspects. And a person with authority, to them, is either a doctor or someone who clearly promises to make them a better doctor, i.e. medical problem solver.

Witman researched how peer group pressure works among doctors in hospital medicine. She derived her core concept of ‘habitus’ from the French sociologist Pierre Bourdieu: the mental structure that individuals develop within a certain structured social environment, the way they are inclined to perceive and value the world and to act accordingly. A habitus develops in interaction between the personal and the social, within the social space of a specific practice. This social ‘field’ is also contested in a way that leaves room for variation and change. The medical habitusis an ensemble of enduring, largely unconscious schemes of perception and evaluation that stimulate and direct a doctor’s action. It contains values and inclinations which are rooted so deeply that they no longer require conscious processes or rational choices at the everyday level. This habitus is, to an important extent, literally embodied: it is molded into a specific pattern of action, movement, demeanor etcetera. It is the typical doctor’s radiation of rationality, goal orientation, self assurance and openness. This is developed from role models and among the peer group, typically ‘between the lines’.

The concept of habitus is foundational and overarching in relation to cognition, competence, behavior and attitude. It denotes the interplay and pattern of these elements and how they are secured into a self evident basic attitude. For doctors this should include an academic attitude, a patient directed attitude and an attitude of accountability. You do not develop such an attitude on your own and in an empty space, but as a functional adaptation to a specific role in a specific practice.

I have come to the conclusion that ethics education (as well as education in academic thinking, but that’s another chapter) should be directed at influencing the developing habitus of medical students. And I’m convinced that this will not work on a diet of ‘applied ethics’. It’s all about habit formation, a habitus encompassing the values that ethics would like to see firmly established in doctor’s actions: mutual trust, patient directedness and accountability. There’s more to that.