MEDICAL MEDICAL PROFESSIONALISM IN PROFESSIONALISM IN THE 21 THE 21 st st CENTURY: CENTURY: IS THERE A NEED FOR IS THERE A NEED FOR REVITALIZATION? REVITALIZATION?
MEDICAL PROFESSIONALISM IN THE 21 st CENTURY: IS THERE A NEED FOR REVITALIZATION?
Dec 17, 2015
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MEDICAL MEDICAL PROFESSIONALISM IN PROFESSIONALISM IN
THE 21THE 21stst CENTURY: CENTURY:IS THERE A NEED FOR IS THERE A NEED FOR
REVITALIZATION?REVITALIZATION?
Socrates: “Tell me: is a doctor in the precise sense…a money-maker or someone who treats the
sick? Tell me about the one who is really a doctor.”
Thrasymachus: “He’s the one who treats the sick.”
Plato, The Republic
Today at the dawn of a new Today at the dawn of a new century, genuine medical century, genuine medical professionalism is in peril professionalism is in peril
Trade or profession?Trade or profession? Market economy a primary Market economy a primary
diminishing factor diminishing factor
““Medicine is, at its center, a moral Medicine is, at its center, a moral enterprise grounded in a covenant enterprise grounded in a covenant of trust. Today, this covenant is of trust. Today, this covenant is significantly threatened.”significantly threatened.”
LudmererLudmerer
• DefinitionsDefinitions
• Evolution Evolution •ConcernsConcerns
•RevitalizationRevitalization•ConclusionsConclusions
MEDICAL MEDICAL PROFESSIONALISMPROFESSIONALISM
DEFINITIONSDEFINITIONS
““A profession…is an occupation that A profession…is an occupation that regulates itself through systematic, regulates itself through systematic, required training and collegial required training and collegial discipline; that has a base in discipline; that has a base in technical, specialized knowledge; technical, specialized knowledge; and that has a service rather than a and that has a service rather than a profit orientation, enshrined in its profit orientation, enshrined in its code of ethics…”code of ethics…”
StarrStarr
A PROFESSION
A PROFESSION
Training is intellectual and involves Training is intellectual and involves knowledge knowledge
Work pursued primarily for others Work pursued primarily for others Success should be measured by Success should be measured by
more than financial return more than financial return
Justice Louis Justice Louis BrandeisBrandeis
SEVEN PILLARS OF A SEVEN PILLARS OF A PROFESSIONPROFESSION
1.1. Technical skill and Technical skill and craftsmanship, craftsmanship, renewed by renewed by continuing educationcontinuing education
2.2. A sense of social A sense of social responsibilityresponsibility
3.3. A knowledge of A knowledge of historyhistory
4.4. A knowledge of A knowledge of literature and the literature and the artsarts
5.5. Personal integrityPersonal integrity
6.6. Faith in the meaning Faith in the meaning and value of lifeand value of life
7.7. The grace of humilityThe grace of humility
E.P. ScarlettE.P. Scarlett
THE PROFESSIONALTHE PROFESSIONAL
Patients first Service/public leadership Nonjudgmental care Collaboration Lifelong learning
THE NON-PROFESSIONALTHE NON-PROFESSIONAL
Dishonest Greedy Impaired Abuses power
Lacks interpersonal skills
Conflict of interest
Self-serving
EVOLUTION OF THE EVOLUTION OF THE PROFESSIONSPROFESSIONS
EVOLUTION OF THEEVOLUTION OF THE PROFESSIONSPROFESSIONS
The Hippocratic OathThe Hippocratic Oath- A vow of service- A vow of service
EVOLUTION OF THEEVOLUTION OF THE PROFESSIONSPROFESSIONS
American society has pitted a belief American society has pitted a belief in egalitarianism against an ideal in egalitarianism against an ideal of individual achievementof individual achievement
Precarious existence in a Precarious existence in a democratic societydemocratic society
Near demise with election of Near demise with election of Andrew JacksonAndrew Jackson
Lincoln reversed the trendLincoln reversed the trend
EVOLUTION OF THE EVOLUTION OF THE PROFESSIONSPROFESSIONS
In United States professional In United States professional designates an independent status designates an independent status with self-regulationwith self-regulation
A social contract – in exchange for A social contract – in exchange for elevated status and a regulated elevated status and a regulated market professionals must market professionals must demonstrate civic responsibility and demonstrate civic responsibility and community leadershipcommunity leadership
IdealIdeal Foundational Foundational ValueValue
RealityReality
Evidence-basedEvidence-based Truth/ScienceTruth/Science UncertaintyUncertainty
Caring, healingCaring, healing CuringCuring Risk-harmingRisk-harming
Open heart/mindOpen heart/mind Accepting, EmpatheticAccepting, Empathetic Arrogant, unmovedArrogant, unmoved
Error-freeError-free Right actionRight action Mistake-proneMistake-prone
AnalyticAnalytic ReflectiveReflective Hassled, knee-jerkHassled, knee-jerk
Self-sacrificingSelf-sacrificing AltruisticAltruistic AvariciousAvaricious
-Inui
THE PROFESSION OF THE PROFESSION OF MEDICINEMEDICINE
THE PROFESSIONS AND THE PROFESSIONS AND THE UNIVERSITYTHE UNIVERSITY
Standardization Standardization Professional degreeProfessional degree
20th CENTURY
Post WWII – many criticsPost WWII – many critics Self interestSelf interest MonopolisticMonopolistic Personal gainPersonal gain
““No longer seen as working quietly for No longer seen as working quietly for the public good the American medical the public good the American medical profession took on a sinister, even anti-profession took on a sinister, even anti-social characteristic, in its role in the social characteristic, in its role in the culture at large. Some influential culture at large. Some influential critics also revised the profession’s critics also revised the profession’s history from a glorious narrative history from a glorious narrative success to a more ominous tale of success to a more ominous tale of hubris.”hubris.”
Rosemary StevensRosemary Stevens
21st CENTURY 21st CENTURY CONCERNSCONCERNS
THE NEW CENTURYTHE NEW CENTURY
Specialization of medicineSpecialization of medicine Faculty reward systemsFaculty reward systems
Publish or perishPublish or perish
Generational gapsGenerational gaps
THE CHANGING FACE OF THE CHANGING FACE OF MEDICINEMEDICINE
Medicine in midst of major Medicine in midst of major ongoing reorganization in response ongoing reorganization in response to drastic regulatory and to drastic regulatory and organizational changesorganizational changes
The growth of HMOsThe growth of HMOs The result is less and less control The result is less and less control
by physiciansby physicians
THE DOCTOR’S DILEMMATHE DOCTOR’S DILEMMA
Patient-CenteredPatient-Centered Advocates for Advocates for
patientspatients Optimal effective Optimal effective
carecare
MarketplaceMarketplace Proxies for the planProxies for the plan
Low cost careLow cost care
Benson
THE DOCTOR’S DILEMMATHE DOCTOR’S DILEMMA
Patient-CenteredPatient-Centered Managed careManaged care Concern for Concern for
individualindividual Bedside rationingBedside rationing
MarketplaceMarketplace Managed costManaged cost ““Distributive ethic”Distributive ethic”
Centralized rule-Centralized rule-based rationingbased rationing
Benson
Profound influence of a market Profound influence of a market economy with perverse financial economy with perverse financial incentives threatens to reduce the incentives threatens to reduce the medical profession to a lowest medical profession to a lowest common denominatorcommon denominator
Physician practice recast as a Physician practice recast as a profit center rather than a group of profit center rather than a group of healershealers
Substitution of a calculation of cost Substitution of a calculation of cost benefit for the ethical relations of benefit for the ethical relations of care and trustcare and trust
Erosion of patients’ Erosion of patients’ TRUST!TRUST!
““Failure to affirm the primacy of the Failure to affirm the primacy of the patients’ welfare will result in a patients’ welfare will result in a loss of the public trust and loss of the public trust and medicine’s slide from a revered medicine’s slide from a revered profession to an occupation profession to an occupation populated with technical experts”populated with technical experts”
HaffertyHafferty
THE NEW CENTURYTHE NEW CENTURY
Gradual disintegration of Gradual disintegration of education communityeducation community
Disappearance of the master Disappearance of the master clinician clinician
Loss of role modelsLoss of role models Loss of mentorsLoss of mentors
THE APPRENTICESHIP OFTHE APPRENTICESHIP OF PROFESSIONALISMPROFESSIONALISM
Acquisition of a knowledge baseAcquisition of a knowledge base Acquisition of skillsAcquisition of skills Acquisition of an understanding of Acquisition of an understanding of
ethical standards, social roles and ethical standards, social roles and responsibilitiesresponsibilities
Formal – what we sayFormal – what we say Hidden – what we doHidden – what we do
CURRICULUMCURRICULUM
FORMAL CURRICULUMFORMAL CURRICULUM
Empathy Empathy CompassionCompassion AltruismAltruism }} What weWhat we
saysay
Most of the critical determinants of Most of the critical determinants of physician identity operate not physician identity operate not within the formal curriculum but within the formal curriculum but in a more subtle, less officially in a more subtle, less officially organized organized hidden curriculumhidden curriculum
The hidden curriculum functions The hidden curriculum functions at the level of organizational at the level of organizational structure and culturestructure and culture
HIDDEN CURRICULUMHIDDEN CURRICULUM
HIDDEN CURRICULUMHIDDEN CURRICULUM
WearinessWeariness Strong distrust of emotionsStrong distrust of emotions Failure of communicationFailure of communication
HIDDEN CURRICULUMHIDDEN CURRICULUM
Ethic of detachmentEthic of detachment Self-interestSelf-interest Over objectivityOver objectivity CYNICISMCYNICISM
1.1. ““Burnout and Self-Reported Patient Care Burnout and Self-Reported Patient Care in an Internal Medicine Residency in an Internal Medicine Residency Program”Program”
2.2. ““Stress in Medical Residency: Status Quo Stress in Medical Residency: Status Quo After a Decade of Reform?”After a Decade of Reform?”
3.3. ““Who is sicker: Patients – or Residents? Who is sicker: Patients – or Residents? Residents’ Distress and the Care of Residents’ Distress and the Care of Patients”Patients”
4.4. ““Heeding the Plea to Deal with Resident Heeding the Plea to Deal with Resident Stress”Stress”
Annals of Internal Annals of Internal MedicineMedicine
March 5, 2002March 5, 2002
JOURNAL ARTICLESJOURNAL ARTICLES
22ndnd set of beliefs - as students, set of beliefs - as students, residents wend their ways through residents wend their ways through years of education they gradually years of education they gradually adopt the medical culture and it’s adopt the medical culture and it’s value system as their own value system as their own abandoning traditional values.abandoning traditional values.
HIDDEN CURRICULUMHIDDEN CURRICULUM
ACADEMIC HEALTH ACADEMIC HEALTH CENTERCENTER
““Moral tone frequently subverts Moral tone frequently subverts rather than supports the rather than supports the development of good professional development of good professional morals.”morals.”
HuddleHuddle
Profound impact of entire Profound impact of entire institutional environment on institutional environment on shaping the attitudes, values, shaping the attitudes, values, beliefs, modes of thought and beliefs, modes of thought and behavior of medical students, behavior of medical students, residents, and facultyresidents, and faculty
ACADEMIC HEALTH ACADEMIC HEALTH CENTERCENTER
““Unless we can convert our learning Unless we can convert our learning environments from crucibles of environments from crucibles of cynicism into cradles of cynicism into cradles of professionalism, no amount of professionalism, no amount of effort in the admissions arena is effort in the admissions arena is going to suffice”going to suffice”
CohenCohen
ACADEMIC HEALTH ACADEMIC HEALTH CENTERCENTER
““Today’s culture of medicine is Today’s culture of medicine is hostile to altruism, compassion, hostile to altruism, compassion, integrity, fidelity, and self-integrity, fidelity, and self-effacement”effacement”
CoulehanCoulehan
REVITALIZATIONREVITALIZATION
REVITALIZATIONREVITALIZATION
Current strategy is inadequate Current strategy is inadequate Production of highly skilled technicians Production of highly skilled technicians
but not necessarily true professionalsbut not necessarily true professionals Must strike a balance between explicit Must strike a balance between explicit
teaching and experiential learning teaching and experiential learning incorporating the values of incorporating the values of professionalismprofessionalism
THE GENERATIONSTHE GENERATIONS
BabyBaby
VeteransVeterans BoomersBoomers CuspersCuspers BustersBusters Gen NextersGen Nexters
1922-43 1944-59 1960-68 1969-79 1980-1922-43 1944-59 1960-68 1969-79 1980-
““In order to define, teach and access In order to define, teach and access professionalism it is imperative to professionalism it is imperative to understand generational understand generational differences, pinpoint conflicts and differences, pinpoint conflicts and determine a more effective determine a more effective definition of professionalism definition of professionalism acceptable to all .”acceptable to all .”
Wagoner and ClayWagoner and Clay
Individuals from different Individuals from different generations eschew different goalsgenerations eschew different goals
BUTBUT Current individuals are no less Current individuals are no less
professional or altruistic than their professional or altruistic than their predecessors predecessors
Their core of professionalism Their core of professionalism remains intactremains intact
REVITALIZING REVITALIZING PROFESSIONALISM PROFESSIONALISM
Faculty development criticalFaculty development critical System of evaluationSystem of evaluation Professional tone and awareness Professional tone and awareness
set from the top!set from the top! Strong institutional supportStrong institutional support
REVITALIZING REVITALIZING PROFESSIONALISMPROFESSIONALISM
Cognitive baseCognitive base Experiential learningExperiential learning ContinuityContinuity Role ModelingRole Modeling MentorshipMentorship
““If the most powerful learning is If the most powerful learning is experiential, and students are close experiential, and students are close observers of the scene in academic observers of the scene in academic health centers, essentially we as faculty health centers, essentially we as faculty are challenged to change what we are challenged to change what we think, say, and do as individuals and as think, say, and do as individuals and as members of a community .”members of a community .”
InuiInui
20032003
REVITALIZING REVITALIZING PROFESSIONALISMPROFESSIONALISM
““The clinical learning environment must The clinical learning environment must be transformed so that students and be transformed so that students and residents can see and experience the residents can see and experience the ideals of medical professionalism at ideals of medical professionalism at work in shaping patient care and can work in shaping patient care and can better understand society’s better understand society’s expectations of them as future expectations of them as future practitioners.”practitioners.”
WhitcombWhitcomb
REVITALIZING REVITALIZING PROFESSIONALISMPROFESSIONALISM
Role of associations important to:Role of associations important to:
- set and maintain standards- set and maintain standards
- to expand and disseminate - to expand and disseminate knowledgeknowledge
- to inform the public- to inform the public Institutions and professional societies are Institutions and professional societies are
necessary to support and stabilize necessary to support and stabilize professionalismprofessionalism
““The greatest challenge in improving The greatest challenge in improving the teaching of professionalism is the teaching of professionalism is to modify the internal culture of to modify the internal culture of the academic health center so that the academic health center so that it better reinforces the values that it better reinforces the values that medical educators wish to impact.”medical educators wish to impact.”
LudmererLudmerer
19991999
ACADEMIC HEALTH ACADEMIC HEALTH CENTERCENTER
““The profession of medicine is under The profession of medicine is under siege. Our resistance must be siege. Our resistance must be professionalism.”professionalism.”
HarrisHarris
20002000
CONCLUSIONSCONCLUSIONS
I. Time honored characteristics of a I. Time honored characteristics of a professionprofession
Specialized education Specialized education Autonomy to set standardsAutonomy to set standards Commitment to serviceCommitment to service
II.II. Profound changes in the Profound changes in the delivery of health care have delivery of health care have introduced real and significant introduced real and significant challenges in regards to challenges in regards to medical medical professionalismprofessionalism
CONCLUSIONSCONCLUSIONS
III.III. Genuine medical Genuine medical professionalism is in perilprofessionalism is in peril
CONCLUSIONSCONCLUSIONS
IV.IV. The hidden curriculum must The hidden curriculum must be be recognized, discussed, and recognized, discussed, and addressedaddressed
CONCLUSIONSCONCLUSIONS
V.V. The 21The 21stst century demands a century demands a revitalization of medical revitalization of medical professionalism which can and professionalism which can and must be accomplished in our must be accomplished in our academic health centersacademic health centers
HEREIN LIES OUR FUTURE!HEREIN LIES OUR FUTURE!
CONCLUSIONSCONCLUSIONS
At its best a professional life enables the individual freedom to
find fulfillment as one advances the well being of society. The
person who succeeds in becoming a professional, mastering its
standards and aims, achieves a substantial focus for living.
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