Volume 8, Issue 3 - March 2025
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Of Professional Virtue: Humility and the Case Against It
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In this issue of The Academy, we join an important conversation about virtues associated with healthcare professionalism. Neither all healthcare professionals nor those teaching and researching in this space espouse a virtue-focused approach to professionalism; however, those who do, as the author of our first article notes, often place humility at (or close to) the top of the list of relevant virtues of those who practice professionalism. In his article, A Case Against Humility, Kevin Christopher McMains, describes a medical case in which it appears that humility should not merely be lower on the list of virtues of professionals but that it actually may be what is not needed. The humble practice of professionals in emergency cases could lead to devastating consequences for some patients. Rather, in some cases, to quote McMains, “To properly serve, it is critically important that we not allow the prizing of humility as a virtue to eclipse the need for a clear, assertive action to save the life of a patient who needs us the most.”
Barret Michalec, who has written widely on the subject of humility, including in The Academy’s predecessor publication, disagrees. In response to Mains’ powerful and provocative suggestion, Michalec affirms the importance of humility, arguing that it need not produce a failure of assertiveness. Rather, humility is rooted in confidence, and the proper expression of the humility of professionals in the case described by Mains would not lead to hesitation. If all know their team roles and are properly humble; the issue does not arise. However, the notion of profession-specific, as opposed to a wider or more humanistic, understanding of humility is problematic. Such an account of the virtue appears, for Michalec, to be self-defeating as it singles out an elevates a subgroup in a way which is – and beg your and his pardon – not humble.
Both articles add a great deal to the ongoing conversation within professionalism circles about humility. They helpfully depart from each other, but noted overlaps are worth reflecting on: Michalec may be right that if humility is at the top of a list, we must look to hidden curricula – and if health professions leaders, educators, and – most importantly – practicing healthcare professionals, are modeling the kind of humility that gives Mains concern, something should be done. The response may be the exercise that Michalec suggests: working out those humility muscles.
Yet, it is important to note that what is valued need not always be valuable. Bracketing the disagreement between Michalec and Mains about the position of humility on the hierarchy of professionalism values, it may be noted that not all character traits or dispositions thought of as virtues are always good or, at least, tis remains an open question. Might it be that the excellent exhibition of humility, if in the wrong context, is better described as a vice? Virtue, at least for one notable thinker on the topic, resided between extremes of both excess and of deficiency.[1] This leads to one of many insights I have gained from reading these thought-provoking pieces in concert, and for which I am grateful to the authors: if some version of humility or some other character trait (or set of practices, behaviors, et cetera) is leading to hesitation and, in turn, to devastating inaction on the part of healthcare professionals, those involved in their training ought to take up that issue. The work of both authors would be instructive in fulfilling that aim.
After working our way through the humility debate, our third article demonstrates the virtue: a reflective piece by a future physician on the consequences of automation bias in healthcare. In “The Impacts of Automation Bias in Healthcare,” Grant Hassan addresses the all-too-common concern increasingly discussed in healthcare contexts, but from a professionalism lens that adds a refreshing if critical eye to the conversation.
The usual announcements and goings on about the professionalism town are peppered through the issue – do consider attending the roundtable, sharing information about APHC’s LEEP program with fitting candidates, and attending the upcoming conference.
Bryan Pilkington, PhD, is Professor of Bioethics, in the Department of Medical Sciences, at Hackensack Meridian School of Medicine, and the Editor-in-Chief of The Academy.
Sources:
[1] Aristotle, W. D. Ross, and J. O. Urmson. 1980. The Nicomachean Ethics. The World’s Classics. Oxford (Oxfordshire) ; New York: Oxford University Press.
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The overhead page echoed through the hospital, “ENT stat to ICU”. Despite our clinic being located as far from the ICU as possible, another faculty member and I left the clinic and hustled there. We arrived at the same time as a group of our residents to find a patient bleeding from his tracheostomy and a multispecialty team of no fewer than 14 health care professionals frozen in place. Our team took care of the immediate clinical problem, but this situation left me with philosophical one: How to understand the panicked inaction of this group of experienced professionals? Why was it bad, in this setting, to be assertive? So where did the inaction come from? As I mulled over the question, one explanation carried explanatory power: an overemphasis on humility.
Several authors look to virtue ethics to guide professional identity formation during medical education and practice.1,2 Humility is among the attributes commonly conceived as a virtue. To enshrine any attribute as a “virtue” is to imply that its application is universally positive. Michalec writes, “Among contemporary scholars, there appears to be general agreement that humility is a socially valuable attribute.”3 While I don’t take issue with this as a general principle, it’s important to ask, “What are the downsides of placing humility at the top of the hierarchy of value?”
When we talk about humility, just what are we talking about? Matchett’s group states: “Physician humility can be conceptualized as an honest and balanced stance toward self, an orientation toward others’ needs and well-being, and a deep-seated appreciation for the privilege of caring for others.”2 They continue describing humility as a stance towards the profession “characterized by gratitude and not entitlement.” The binary nature of the conversation around humility sits uncomfortably. In much the same way as “work” and “life” are often pitted against one another, the polarity between “gratitude” and “entitlement” feels false. By way of example, as a surgeon, at the hospitals where I have credentials, I am “entitled” to bear the responsibility for expert conduct of surgical care (residency, boards, hospital privileges underpin this entitlement). I am “entitled” to navigate the emotional toll of human disease on my patients, trainees, and family. I can simultaneously be grateful for that weighty responsibility. Grateful for the patient’s trust, and for the other members of the care team who I treat with respect.
Another element of this conversation that we need to make explicit: Many people thinking, talking, and writing about the need for humility in medicine use this conversation to chasten what they perceive as poor physician behavior. Tongue in cheek, we might say “Humility is a great virtue for someone else to have.” In “The Righteous Mind”4, Jonathan Haidt describes the mental processes that lead each of us to curate incoming evidence in support of groups with which we affiliate, while applying more rigorous judgments to groups to which we don’t belong. As a result, each of us naturally judges our own team, service, and profession as more virtuous than others. It seems perhaps too easy to brand someone else’s perspective as lacking humility, and in so doing, excoriating them – does such an act itself seem humble? Or is it a way to protect our own group and our own method of engagement with care? Haidt identifies six “moral foundations” from which judgements surrounding virtue arises: Care/Harm, Fairness/Cheating, Loyalty/Betrayal, Authority/Subversion, Sanctity/Degradation, Liberty/Oppression. Awareness of another person or profession’s bent towards a moral foundation different from our own might well serve our teams and patients better than presuming lack of virtue.
Learning to care for human beings not only carries an enormous cognitive load, but also an enormous affective load. During the process of “becoming”, trainees in the health professions face daily challenges to their identity and self-concept. All of that is happening while we, as faculty, simultaneously, and necessarily, push each of trainee beyond their current capabilities, into discomfort and development.1 Tagney identifies different emotional responses to such challenges: guilt and shame.5 On a daily basis, many medical trainees face threats to their sense of self-worth that accusations of “lack of humility” (read: failure of virtue) only serve to magnify. Each of us brings to work family history, emotional wounds, patterns of behavior/self-concept developed to protect against these threats to our identities. It is my opinion that, as a profession, we have not yet taken these dynamics seriously enough. I’m no apologist for abusive behavior. Rather, from all sides, I would encourage considering the acute and chronic stresses these professionals endure and extending them a measure of grace.
Where does this leave humility? The clinical vignette above highlights an unintended consequence of placing humility atop of a value hierarchy- framing assertive, necessary action as a violation of virtue. This tendency not only poses a risk to patients, it expands to include trainees as second victims.6 In light of this, it’s worth reconsidering what we are advocating: Mutual respect? Civility? Trustworthy interactions? Each of these terms leaves room for the necessary exercise of self-efficacy.
There is a construction that may help us with deciding what circumstances merit deviation from prioritizing humility. In “Thinking, Fast and Slow,”7 Daniel Kahneman describes two systems of thinking: System 1 (“Fast thinking”) is the default system, functioning automatically, recognizing patterns, and defaulting to heuristics. System 2 (“Slow thinking”) is deliberate, considered, and makes demands on depletable mental resources. Applying a similar approach to our interprofessional teams, under most circumstances, we default to known heuristics- civility, mutuality, consensus building. In situations where a patient’s need demands swift action, we must shift from this default posture, and lay aside the appeals to humility that lead to inaction.
Michalec endorses Tagney‘s description of humility: “a relatively low self-focus, appreciation of others’ contributions, and recognition that one is but a part of a larger universe.” This description works on several levels. Through most of history, the many distinct celestial bodies interact with one another, contributing to the expansion of the universe. In most situations, the interactions among the health professions and the individuals who inhabit them expand the universe of expertise brought to patient care. However, at one moment in time, the universe existed as a singularity. In a similar way, there are times when a patient requires the action of a single person in a specific clinical situation. One moment. One patient. One healing action. To properly serve, it is critically important that we not allow the prizing of humility as a virtue to eclipse the need for a clear, assertive action to save the life of a patient who needs us the most.
Kevin Christopher McMains MD, Otolaryngology (ENT), Uniformed Services University of the Health Sciences in San Antonio, United States
References:
- Aluri JT, Chisolm MS, Liao L. Sacrifice as a Part of Medical Education: A Reflection on the COVID-19 Pandemic. J Med Educ Curric Dev. Jan-Dec 2024;11:23821205241250144. doi:10.1177/23821205241250144
- Matchett CL, Usher EL, Ratelle JT, et al. Physician Humility: A Review and Call to Revive Virtue in Medicine. Ann Intern Med. Sep 2024;177(9):1251-1258. doi:10.7326/m24-0842
- Michalec B, Gómez-Morales A, Tilburt JC, Hafferty FW. Examining Impostor Phenomenon Through the Lens of Humility: Spotlighting Conceptual (Dis)Connections. Mayo Clinic Proceedings. 2023;98(6):905-914. doi:10.1016/j.mayocp.2023.01.020
- Haidt J. The Righteous Mind: Why Good People are Divided by Politics and Religion. Penguin Books Limited; 2012.
- Tangney JP, Dearing RL. Shame and Guilt. Guilford Publications; 2003.
- Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. Bmj. Mar 18 2000;320(7237):726-7. doi:10.1136/bmj.320.7237.726
- Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011.
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“To properly serve, it is critically important that we not allow the prizing of humility as a virtue to eclipse the need for a clear, assertive action to save the life of a patient who needs us the most.”
This concluding sentiment and the compelling clinical vignette in “A Case Against Humility” raise an important question: Can humility coexist with decisive, assertive action in medicine? The answer is an emphatic yes. The piece rightly critiques inaction in the face of medical crises but, I believe, incorrectly attributes it to a potential (over)emphasis on the value of humility. Promoting humility among current and future doctors does not usher paralyzing deference; it empowers clinicians to recognize their limitations, collaborate effectively, foster continuous learning, acknowledge uncertainty, and see their role as one of many devoted to patient care and well-being.1,2
In turn, humility should not be framed as the antithesis of assertiveness but as its necessary counterpart. Similarly, humility is not the contrast of confidence – as confidence is at the root of humility.3 True humility does not stifle action—it enhances it by ensuring that action is purposeful, informed, thoughtful, and responsive to the needs of patients and colleagues alike. If the concern is that medical professionals and students sometimes hesitate in moments of crisis, the solution is not to discard humility but to clarify its role(s) and presence. In this sense, it is important to explore where/how/if humility is reflected in the explicit, implicit, and hidden curricula of medical education and training and if current and future practitioners are provided formal opportunities to strengthen humility-related “muscles.”4
Moreover, the proposed assumption that humility is placed “…at the top of the hierarchy of value…” for medical students and practicing doctors is a slight exaggeration. Perhaps humility is indeed having a moment, but one could argue that values such as compassion, integrity, empathy, and resilience, among others, are more frequently touted within professionalism-oriented literature, echoed in clinical training, and, perchance, even more likely to be emblazoned on medical schools’ mission statements. For example, a quick Google Scholar search (performed 2/5/25) for “Humility and Medical Education” yields 266,000 results, whereas “Empathy and Medical Education” yields 1,160,000 results, and “Integrity and Medical Education” yields about 3,740,000 results.
I support challenging Matchett and colleagues'5 conceptualization of “physician humility.” The term “physician humility” reflects the dangerous practice of conceptual ethnocentrism in Medicine and Medical Education literature, and their specific framing does imply an either/or approach. Recognizing one’s entitlement to perform a role—such as a surgeon operating or a psychiatrist prescribing—does not negate the need for gracious humility in practice. Nor does the practice of humility disaffirm the entitlements associated with a particular role. Regardless of specialty or earned entitlements, physicians can demonstrate humility through confidence in their expertise, awareness of limitations, seeking input when appropriate, collaborating with patients and caregivers, and remaining open to new knowledge. A doctor can be entitled in role and humble in practice. The challenge arises, however, when perceived entitlements reinforce status hierarchies and shape humility-related expectations.6 To better explore humility’s role in
healthcare and health professions education, scholars should adopt broader frameworks, such as Tangney’s7 conceptualization of humility and the notion of Professional Humility8, which integrates Intellectual and Cultural Humility and explicitly acknowledges the existing occupational status hierarchy nested within care delivery.
Type-casting humility (i.e., “physician humility”) contradicts its inherently relational nature. How can members of one social group, such as physicians, be open to the contribution of others or acknowledge that they are part of a much larger group, organization, or universe if their understanding of humility is tied to discussions exclusively within their own micro-verse? Moreover, if physicians see themselves as situated within their own special version of a social practice such as humility, then why not nurses, physician assistants, clinical social workers, physical therapists, or any other potential member of a healthcare delivery team, including patients be seen as having their own unique version of humility as well?
In conclusion, cultivating humility in current and future physicians does not undermine assertiveness or confident clinical decision-making. Instead, humility fosters openness to others’ perspectives, encourages feedback, and supports patient-centered, team-based care. When viewed not as a physician-specific trait but as a humanistic value that bridges status differentials, its importance in both professional and personal life becomes clear.
Barret Michalec’s research focuses on socialization and professionalization in health professions education, particularly the development of socio-emotional and team-based skills. He also examines challenges in health, healthcare, and pre-professional pathways, emphasizing socio-cultural design and organizational cultural.
References:
- Michalec B, Cuddy M, Felix K, Gur-Arie R, Tilburt JC, Hafferty FW. Positioning humility within healthcare delivery – from doctors’ and nurses’ perspectives. Hum Factors Healthc. 2024;5:1-10. doi:10.1016/j.hfh.2023.100061
- Michalec B, Papanagnou D, Raj L, et al. Exploring the presence and roles of humility in situations of uncertainty. AEM Educ Train. Forthcoming. doi:10.1002/aet2.11055
- Michalec B, Gómez-Morales A, Tilburt JC, Hafferty FW. Examining impostor phenomenon through the lens of humility: spotlighting conceptual (dis)connections. Mayo Clin Proc. 2023;98(6):905-914.
- Michalec B, Hafferty FW, Piemonte N, Tilburt J. The ambiguities of humility: a conceptual & historical exploration in the context of health professions education. In: Brown MEL, Veen M, Finn GM, eds. Applied Philosophy for Health Professions Education: A Journey Towards Mutual Understanding. Springer; 2022:351-370.
- Matchett CL, Usher EL, Ratelle JT, et al. Physician humility: a review and call to revive virtue in medicine. Ann Intern Med. 2024;177(9):1251-1258. doi:10.7326/M24-0842
- Michalec B, Piemonte N, Hafferty FW. The elephant in the room: examining the connections between humility and social status. J Humanit Soc Sci. 2021;3(4):72-79.
- Tangney JP. Humility: theoretical perspectives, empirical findings and directions for future research. J Soc Clin Psychol. 2000;19(1):70-82.
- Michalec B, Xyrichis A, Arenson C. "Professional humility": introducing a new framework to advance interprofessionalism. J Interprof Care. 2024;38(4):587-592. doi:10.1080/13561820.2024.2326974
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The Impacts of Automation Bias in Healthcare
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When Linda Skitka and Kathleen Mosier first defined automation bias in 1997 as “the tendency to use automated cues as a heuristic replacement for vigilant information seeking and processing” 1 it was unclear how pertinent this bias would become. As the world has progressed over the last 28 years, we have seen automation reach extraordinary heights. It has become an integral part in both everyday tasks and life changing cures. As we look forward it is nearly impossible to grasp the potential that machine learning could have. However, one thing has become abundantly clear, and that is AI has profoundly situated itself within the medical field. In a recent data analysis by Kalra et al. it was concluded that, “AI has proved its efficiency in predictive diagnosis by predicting accurately, various diseases like cancer, pulmonary disorders, genetic disorders etc.” 2. Ultimately, AI has continued to prove its potential usefulness within our healthcare system. The current environment in the healthcare realm is one of hesitancy yet inevitability, uncertainty yet excitement. The leaders of our sector have immensely important decisions to make about the direction we will go. It is of the utmost importance that we guide our decision making on what is best for the patient. More importantly than ever, we must emphasize the interpersonal skills and judgement that defines us as professionals. In the words of Skitka and Mosier we must continue to be at the forefront of “vigilant information seeking and processing.”
Since the term automation bias has been coined, various studies have tried to quantify the influence it could have on different disciplines. One of the earliest examples of machine learning being used for Clinical Decision Support (CDS) has been the use of electronic prescribing (eRx) devices. While these devices have unequivocally decreased incorrect prescriptions, the evidence also shows that when devices provide incorrect suggestions, physicians are much more likely to accept incorrect prescriptions 3. The literature proves that our trust in automated tools has the power to blind us from our professional duties as physicians. Everyday more tools that utilize Artificial Intelligence are entering the market, thus the topic of automation bias needs to be at the forefront of discussion. With the current exponential growth in artificial intelligence we have already seen it outperform physicians in diagnosing prostate cancer from MRI’s 4. As more research begins to show superior diagnostic accuracy in Artificial Intelligence our trust in these systems to be accurate will continue to increase. This growth is exciting, but also leaves us susceptible to increased automation bias. It is imperative that medical students and physicians alike are educated on this topic. It is of equal importance that machine learning software is developed and tested in a way that considers automation bias before it is ever implemented in a clinical setting.
A transition into a new age of medicine is happening in-front of our eyes whether we like it or not. With all the issues our healthcare system already faces, we cannot afford to fumble how we handle the impending integration of AI. While aspects of professionalism span all workplaces, there is an extra obligation that physicians must uphold to their patient. To me, healthcare professionalism is defined by the constant pursuit of improvement for the patient and the system. We must not lose sight of our roles as professionals despite the everchanging nature of healthcare. Machine learning in clinical settings has the power to optimize patient results, but without correct implementation we risk harming patients. As I reflect further on my future as a physician, I am unsure what decisions will be made regarding how our healthcare systems use artificial intelligence. It is impossible to predict the barriers that technology will break over the next half-century, but over that time I will always work tirelessly to be a proponent of limiting automation bias. By emphasizing the risks of automation bias we ensure that the pursuit of improvement for the patient and the system is maintained. It is essential that we work collaboratively to ensure that automation and vigilant decision making are not mutually exclusive.
Grant Hassan is a first-year medical student at HMSOM and completed his B.S. in Biochemistry at the University of Washington.
Works Cited:
- Mosier K, Skitka LJ. Human decision makers and automated decision aids: made for each other? In: Parasuraman R, Mouloua M, eds. Automation and Human Performance: Theory and Applications. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, 1996:pp. 201–20
- Kalra N, Verma P, Verma S. Advancements in AI based healthcare techniques with FOCUS ON diagnostic techniques. Comput Biol Med. 2024 Sep;179:108917. doi: 10.1016/j.compbiomed.2024.108917. Epub 2024 Jul 25. PMID: 39059212.
- Lyell D, Magrabi F, Raban MZ, Pont LG, Baysari MT, Day RO, Coiera E. Automation bias in electronic prescribing. BMC Med Inform Decis Mak. 2017 Mar 16;17(1):28. doi: 10.1186/s12911-017-0425-5. PMID: 28302112; PMCID: PMC5356416.
- Saha A, Bosma JS, Twilt JJ, van Ginneken B, Bjartell A, Padhani AR, Bonekamp D, Villeirs G, Salomon G, Giannarini G, Kalpathy-Cramer J, Barentsz J, Maier-Hein KH, Rusu M, Rouvière O, van den Bergh R, Panebianco V, Kasivisvanathan V, Obuchowski NA, Yakar D, Elschot M, Veltman J, Fütterer JJ, de Rooij M, Huisman H; PI-CAI consortium. Artificial intelligence and radiologists in prostate cancer detection on MRI (PI-CAI): an international, paired, non-inferiority, confirmatory study. Lancet Oncol. 2024 Jul;25(7):879-887. doi: 10.1016/S1470-2045(24)00220-1. Epub 2024 Jun 11. PMID: 38876123; PMCID: PMC11587881.
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Registration Now Open
The Academy for Professionalism in Health Care is an inclusive organization which welcomes all professionals and their trainees who are devoted to the study and advancement of professionalism in health-related fields. The hybrid international conference will take place in-person at Rosalind Franklin University of Science and Medicine (North Chicago, Illinois, USA) and virtually using Zoom. The conference will include 3 Keynote Presentations, 3 Symposia, 1 Fireside Chat, 15 How-to Workshops, 3 Problem-solving Sessions, 6 Panels, 28 Oral and 8 Flash Presentations. All sessions are hybrid and will be recorded for future viewing.
There will be ample opportunities to network with colleagues. Over 60 sessions will cover topics such as:
- Theoretical Concepts & Frameworks Related to Professionalism and Trust
- Patient Trust - Difficult to Gain, Easy to Lose
- Trust Threats in Multicultural Learning Environments
- Trust Building within Interprofessional Teams
- Trust in Research and Processes of Protection. e.g. IRB
- Assessment & Remediation of Trust-Related Professionalism Lapses
- Re-building Trust, a Professional Obligation after Public Health Misinformation Campaigns
- How Trustworthy is Technology, e.g. AI?
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