“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, July 28, 2007

Professionalism in medicine (part I)

“It is dangerous to be right in matters on which
the established authorities are wrong”

In the recent orthopaedic press, the topic of professionalism has been brought up. The AAOS has put out new standards for professionalism on two topics, Advertising by Orthopaedic Surgeons and Orthopaedist-Industry Conflicts of Interest. This made me ask several questions. First, what is the definition of professionalism; even more important, what is medical professionalism? Second, have these views of professionalism changed and are they effected by the current changes in residencies today? The first question will be addressed in this post.

Most would say that professionalism should be inherently understood in medicine. It is clearly stated in the Hippocratic oath we take when we graduate medical school. But, most medical schools don't take the original Hippocratic oath; they take the abridged version. There are some that feel Hippocratic Oath is inadequate to address the realities of a medical world that has witnessed huge scientific, economic, political, and social changes, a world of legalized abortion, physician-assisted suicide, and pestilences unheard of in Hippocrates' time.

Hippocratic Oath -- Classical Version

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.
Now compare this with the modern oath.

Hippocratic Oath—Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.
Truly times have changed since the original oath was written. How have we adjusted things so that they fit modern days? This is yet to be seen.

So, what is considered a profession? One basic definition of a profession is
an occupation, especially one which requires an advanced education. One more fitting for the medical profession itself is:
an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

Cruess, S.R, Johnston, S. and Cruess, R.L. ‘Profession’: A working definition for medical educators. Teaching and Learning in Medicine, 2004; 16: 74-76.
With this understanding of what the profession is, then what would the definition of professionalism be? Many would agree that humanistic values such as honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, should be at the core of medical professionalism. The humanistic values are not a requisite to professional behavior, but the practice of medicine is a human endeavor. In an article by Swick titled Toward a normative definition of medical professionalism (Academic Medicine, 2000; 75: 612-616.), there was an attempt to put into words what should be a general understanding of what is considered to be professionalism. In this article, a number of points were made.
  • Physicians subordinate their own interests to the interests of others;
  • Physicians adhere to high ethical and moral standards:
  • Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served;
  • Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for self, patients, peers, attendings, nurses, and other health care professionals;
  • Physicians exercise accountability for themselves and for their colleagues;
  • Physicians recognize when there is a conflict of interest to themselves, their patients, their practice
  • Physicians demonstrate a continuing commitment to excellence;
  • Physicians exhibit a commitment to scholarship and to advancing their field;
  • Physicians must (are able to) deal effectively with high levels of complexity and uncertainty;
  • Physicians reflect critically upon their actions and decisions and strive for IMPROVEMENT in all aspects of their work
  • Professionalism incorporates the concept of one’s moral development
  • The profession of medicine is a “self regulating” profession, dependent on the professional actions and moral development of its members; this concept includes one’s responsibility to the profession as a healer
  • Professionalism includes receiving and responding to critiques from peers, students, colleagues, superiors
  • Physicians must demonstrate sensitivity to multiple cultures
  • Physicians must maintain competence in the body of knowledge for which they are responsible; they must have a commitment to life long learning
A document titled Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-246) set forth what they termed a set of commitments. This was put out by the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine and in this they stated there are three fundamental principles set the stage for the heart of the charter. In its preamble, they state that
Professionalism is the basis of medicine’s contract with society.
The three principles that make up this charter are:
  1. Principle of primacy of patient welfare.
  2. Principle of patient autonomy.
  3. Principle of social justice.
Thcharter also sets forth some basic professional responsibilities.
  • Commitment to professional competence.
  • Commitment to honesty with patients.
  • Commitment to patient confidentiality.
  • Commitment to maintaining appropriate relations with patients.
  • Commitment to improving quality of care.
  • Commitment to improving access to care.
  • Commitment to a just distribution of finite resources.
  • Commitment to scientific knowledge.
  • Commitment to maintaining trust by managing conflicts of interest.
  • Commitment to professional responsibilities.
The summary of this document states:
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the privacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.
The gauntlet has been set forth and the powers have established some rules of what should be considered professionalism. Do these hold up in our current times? Do the new generations of residents feel the same calling to medicine and dedication to their patients? Have our eyes been so clouded by the thoughts of work hour restrictions, CMS payment schedules, and increase in malpractice cases that we have forgotten our social obligation to our patients? The Hippocratic oath that we took upon our graduation, although it may not completely apply to todays medical climate, gives us some of the basic tenets under which we should practice. I don't have all the answers. We all are born in different eras and trained under different guidelines. We listen to different music and have different beliefs. But, we are all physicians. That we have in common. A common purpose to provide appropriate care to our patients with in the realm of our current knowledge. A common purpose to be professional.

“We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.”
~ Friedrich Nietzsche

NEXT: Professionalism in medicine (part II)
Have these views of professionalism changed and are they effected by the current changes in residencies today?


BoneDoc23 said...

Defining professionalism was a common assignment from the program director of my residency to the trainees.

This is an interesting topic. I do not know where you are going with the last paragraph though. I do not know how any mandate by "powers that be" can speak more loudly than the actions of your superiors. The barrage of reports in the news about ill-prepared surgeon owned hospitals/centers and ridiculous drug company/physician arrangements is more troubling than the possible impact of any regulation. Your post about peds ortho is a great example. It talks about your mentor(s); not the system, the hospital, the rules, etc. Being trained by people who do not hold the tenets of professionalism to be sacred will be far more damning than work hour restrictions or CMS payments. Further, many such mandates are a result of changes in professional behaviors, not a cause. Stark and Anti-Kickback don't exist just because, but because those violations were taking place and to sum it up were breaking the social contract to which physicians are bound. That is the thing you failed to point out in a past post (I can't find it though) about training and the government coming and looking for fraud such as the attending not being in the hospital and how it hurt the system: There was fraud going on. Fraud is a criminal offense. Those changes were not a result of the man picking on the docs, it was a slap on the wrist for years of federal offenses.

In my opinion, addressing the actions of people committing these types of actions will get us to a better place much quicker than harping on government regulations and generational differences. Ideally, we would be able to rely on the social contract but that would be too hard. Physicians are targets any way you cut it. As much as it hurts, there are people who shop for doctors to sue. When the cost of medical care comes up, the greedy doctor is an easy target despite how little of bill gets spent there. Doctors do not make the money that so many other professionals do. The contract isn't being held up well on either end.

Someonect said...

jeffrey, thanks for commenting.

i think you are right, we should "lead by example." this was the first of several posts on this topic. your point is well taken.

professionalism is more than just one persons actions. it should also not be effected by the actions of the government or generational changes. our view of professionalism does change based on our experience and training. some older physicians may have a problem with some of the ways medicine is practiced today, but times have changed.

if you don't wear a tie, are you not professional? if you have a tattoo, are you less professional? this is something very generational. not knowing everything about you patient in the past may have been seen as unprofessional.

i think there is a lot more to be said on this topic.