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The balance of health care and professionalism
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“To have a group of cloistered clinicians away completely from the broad current of professional life would be bad for teacher and worse for student. The primary work of a professor of medicine in a medical school is in the wards, teaching his pupils how to deal with patients and their diseases.” — William Osler, founding professor at Johns Hopkins University
Sad and lonely all the time
That’s because I’ve got a worried mind
You know the world is in an uproar
The danger zone is everywhere, everywhere
“The Danger Zone,” Ray Charles (B side of 1961 single “Hit the Road Jack” [Percy Mayfield])
My attention was recently refocused on the topic of professionalism by an article and an editorial in the October issue of The Journal of Pediatrics that reflected upon the teaching of professionalism in residency and medical school. The article surveyed young pediatricians on their training in ethics and professionalism and reported significant gaps in their training. The editorial underlined the challenges of residency programs, specifically as it applies to social media, highlighting inappropriate postings by residents.
Professionalism and ethics speak to the soul of medical practice. A common portrayal of the issue is that of “trust” in the medical profession being under siege, failed by its reliance on an old, elitist model, and thus requiring a new structure, patient-centered and less exclusively professional to move forward. These are very old debates. Social media might be a new actor but its use by young professionals only allows a wider audience — not a substantive change in behavior.
Issue of professionalism
I find the current discussion of professionalism overworked. Academia is fascinated by the topic and it drives our profession’s dark side — the bureaucratic hierarchy of our medical schools, residency programs and professional organizations. It largely ignores those of us who practice medicine on a daily basis. The physician leaders have traveled from the bedside and the greater their interest in the philosophy of medicine, the more complete their contamination by the business of medicine. And therefore the more complex their solutions to the “problems” of medicine become. We then reach “the danger zone” that Ray Charles captures in the above song.
William T. Gerson
Professionalism is central to the current and future of medicine just as it has been for centuries. We have as always a moral contract between the medical profession and society. The critical elements of this contract reflect the granting of a monopoly over the use of a body of scientific knowledge, along with significant autonomy in the practice of medicine both to act in the best interest of the patient and to self-regulate education, training and standards of care. This is with the understanding that in exchange the profession guarantees competence, integrity, morality, service and altruism.
On the professional side exists our codes of ethics, whereas focused on our relationships with our patients, also enlightens our ever-changing relationships and accountabilities to our professional organizations, and if not self-employed to our employers (now often complex health care systems, or for some governmental bodies — their code of ethics is another story). Our tension in this negotiation with the wider society often involves the expectation of prestige and financial rewards. For society, the exclusivity of the monopoly, the requirement of service for the public good and the degrees of autonomy define its tension with the profession. With the growing influence of both the government and corporations in the health care system, the relationship, and thus the negotiation, is even more complex.
Regardless, concern over our professional status has been longstanding and persistent. The nature of our profession, of any profession, is based on the social contract, and this contract is always being negotiated. In times of great changes in either the science of medicine or in the society as a whole, the nature of the negotiation changes. Unease brings about a heightened sense of unbalance in a long and beneficial relationship. The recent rapid increase in the pace of change in current medicine, specifically in systems of care, has brought significant disquiet within medicine. The result has been many attempts by bodies of physicians to provide charters or redefinitions of medical professionalism. Many are painful to read.
Science and practice of medicine
In pediatrics, the answers are not difficult to delineate: patient focus, public good. Pediatrics has always stood for these twin towers. We are lucky in pediatrics that our professional organizations have always been patient-focused. The mission of the AAP is the well-being of children. The American Board of Pediatrics has repeatedly focused on discussions of professionalism as it applies to pediatrics since the 1970s. The privilege of self-regulation requires an absolute obligation to guarantee the competence of its members. Continuous improvement and excellence in care underpin the science and practice of medicine.
In our medical schools and our training programs, the answers also seem simple. The central place in both belongs to the education of the physician. Put the professor of medicine in the wards teaching. Our current focus on the amount to be taught and the ever increasing body of knowledge is horribly misplaced, as are our offerings on the business model and altar of academic practice. We need to invest in the individual student.
The goal is to transfer to them compassion toward the human condition, along with a never-ending scientific curiosity over human biology. The responsibility of the student and resident is to develop the capacity to understand the human condition and to acquire the critical skills to integrate clinical information, both in sickness and health. To do this, they need the presence of the professor. Osler knew this, as did Hippocrates for that matter; they just need some extra help today.
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