MEDICAL PROFESSIONALISM IN THE 21st CENTURY: IS THERE A NEED FOR REVITALIZATION?

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MEDICAL PROFESSIONALISM IN THE 21st CENTURYIS
THERE A NEED FOR REVITALIZATION?
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• Socrates Tell me is a doctor in the precise
  sensea money-maker or someone who treats the
  sick? Tell me about the one who is really a
  doctor.
• Thrasymachus Hes the one who treats the
  sick.
• Plato, The Republic

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• Today at the dawn of a new century, genuine
  medical professionalism is in peril
• Trade or profession?
• Market economy a primary diminishing factor

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• Medicine is, at its center, a moral enterprise
  grounded in a covenant of trust. Today, this
  covenant is significantly threatened.
• Ludmerer

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MEDICAL PROFESSIONALISM

• Definitions
• Evolution
• Concerns
• Revitalization
• Conclusions

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DEFINITIONS
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A PROFESSION

• A professionis an occupation that regulates
  itself through systematic, required training and
  collegial discipline that has a base in
  technical, specialized knowledge and that has a
  service rather than a profit orientation,
  enshrined in its code of ethics
• Starr

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A PROFESSION

• Training is intellectual and involves knowledge
• Work pursued primarily for others
• Success should be measured by more than financial
  return
• Justice Louis Brandeis

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SEVEN PILLARS OF A PROFESSION

• Technical skill and craftsmanship, renewed by
  continuing education
• A sense of social responsibility
• A knowledge of history

• A knowledge of literature and the arts
• Personal integrity
• Faith in the meaning and value of life
• The grace of humility
• E.P. Scarlett

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THE PROFESSIONAL

• Patients first
• Service/public leadership
• Nonjudgmental care
• Collaboration
• Lifelong learning

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THE NON-PROFESSIONAL

• Dishonest
• Greedy
• Impaired
• Abuses power

• Lacks interpersonal skills
• Conflict of interest
• Self-serving

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EVOLUTION OF THE PROFESSIONS
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EVOLUTION OF THE PROFESSIONS

• The Hippocratic Oath
• - A vow of service

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EVOLUTION OF THE PROFESSIONS

• American society has pitted a belief in
  egalitarianism against an ideal of individual
  achievement
• Precarious existence in a democratic society
• Near demise with election of Andrew Jackson
• Lincoln reversed the trend

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EVOLUTION OF THE PROFESSIONS

• In United States professional designates an
  independent status with self-regulation
• A social contract in exchange for elevated
  status and a regulated market professionals must
  demonstrate civic responsibility and community
  leadership

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THE PROFESSION OF MEDICINE
-Inui
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THE PROFESSIONS AND THE UNIVERSITY

• Standardization
• Professional degree

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20th CENTURY

• Post WWII many critics
• Self interest
• Monopolistic
• Personal gain

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• No longer seen as working quietly for the public
  good the American medical profession took on a
  sinister, even anti-social characteristic, in its
  role in the culture at large. Some influential
  critics also revised the professions history
  from a glorious narrative success to a more
  ominous tale of hubris.
• Rosemary Stevens

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21st CENTURY CONCERNS
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THE NEW CENTURY

• Specialization of medicine
• Faculty reward systems
• Publish or perish
• Generational gaps

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THE CHANGING FACE OF MEDICINE

• Medicine in midst of major ongoing reorganization
  in response to drastic regulatory and
  organizational changes
• The growth of HMOs
• The result is less and less control by physicians

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THE DOCTORS DILEMMA

• Patient-Centered
• Advocates for patients
• Optimal effective care

• Marketplace
• Proxies for the plan
• Low cost care
• Benson

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THE DOCTORS DILEMMA

• Patient-Centered
• Managed care
• Concern for individual
• Bedside rationing

• Marketplace
• Managed cost
• Distributive ethic
• Centralized rule-based rationing
• Benson

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• Profound influence of a market economy with
  perverse financial incentives threatens to reduce
  the medical profession to a lowest common
  denominator

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• Physician practice recast as a profit center
  rather than a group of healers
• Substitution of a calculation of cost benefit
  for the ethical relations of care and trust
• Erosion of patients TRUST!

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• Failure to affirm the primacy of the patients
  welfare will result in a loss of the public trust
  and medicines slide from a revered profession to
  an occupation populated with technical experts
• Hafferty

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THE NEW CENTURY

• Gradual disintegration of education community
• Disappearance of the master clinician
• Loss of role models
• Loss of mentors

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THE APPRENTICESHIP OF PROFESSIONALISM

• Acquisition of a knowledge base
• Acquisition of skills
• Acquisition of an understanding of ethical
  standards, social roles and responsibilities

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CURRICULUM

• Formal what we say
• Hidden what we do

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FORMAL CURRICULUM

• Empathy
• Compassion
• Altruism

What we say
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HIDDEN CURRICULUM

• Most of the critical determinants of physician
  identity operate not within the formal curriculum
  but in a more subtle, less officially organized
  hidden curriculum
• The hidden curriculum functions at the level of
  organizational structure and culture

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HIDDEN CURRICULUM

• Weariness
• Strong distrust of emotions
• Failure of communication

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HIDDEN CURRICULUM

• Ethic of detachment
• Self-interest
• Over objectivity
• CYNICISM

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JOURNAL ARTICLES

• Burnout and Self-Reported Patient Care in an
  Internal Medicine Residency Program
• Stress in Medical Residency Status Quo After a
  Decade of Reform?
• Who is sicker Patients or Residents?
  Residents Distress and the Care of Patients
• Heeding the Plea to Deal with Resident Stress
• Annals of Internal Medicine
• March 5, 2002

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HIDDEN CURRICULUM

• 2nd set of beliefs - as students, residents wend
  their ways through years of education they
  gradually adopt the medical culture and its
  value system as their own abandoning traditional
  values.

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ACADEMIC HEALTH CENTER

• Moral tone frequently subverts rather than
  supports the development of good professional
  morals.
• Huddle

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ACADEMIC HEALTH CENTER

• Profound impact of entire institutional
  environment on shaping the attitudes, values,
  beliefs, modes of thought and behavior of medical
  students, residents, and faculty

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ACADEMIC HEALTH CENTER

• Unless we can convert our learning environments
  from crucibles of cynicism into cradles of
  professionalism, no amount of effort in the
  admissions arena is going to suffice
• Cohen

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• Todays culture of medicine is hostile to
  altruism, compassion, integrity, fidelity, and
  self-effacement
• Coulehan

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REVITALIZATION
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REVITALIZATION

• Current strategy is inadequate
• Production of highly skilled technicians but not
  necessarily true professionals
• Must strike a balance between explicit teaching
  and experiential learning incorporating the
  values of professionalism

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THE GENERATIONS

• Baby
• Veterans Boomers Cuspers Busters
  Gen Nexters
• 1922-43 1944-59 1960-68
  1969-79 1980-

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• In order to define, teach and access
  professionalism it is imperative to understand
  generational differences, pinpoint conflicts and
  determine a more effective definition of
  professionalism acceptable to all .
• Wagoner and Clay

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• Individuals from different generations eschew
  different goals
• BUT
• Current individuals are no less professional or
  altruistic than their predecessors
• Their core of professionalism remains intact

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REVITALIZING PROFESSIONALISM

• Faculty development critical
• System of evaluation
• Professional tone and awareness set from the top!
• Strong institutional support

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REVITALIZING PROFESSIONALISM

• Cognitive base
• Experiential learning
• Continuity
• Role Modeling
• Mentorship

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• If the most powerful learning is experiential,
  and students are close observers of the scene in
  academic health centers, essentially we as
  faculty are challenged to change what we think,
  say, and do as individuals and as members of a
  community .
• Inui
• 2003

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REVITALIZING PROFESSIONALISM

• The clinical learning environment must be
  transformed so that students and residents can
  see and experience the ideals of medical
  professionalism at work in shaping patient care
  and can better understand societys expectations
  of them as future practitioners.
• Whitcomb

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REVITALIZING PROFESSIONALISM

• Role of associations important to
• - set and maintain standards
• - to expand and disseminate knowledge
• - to inform the public
• Institutions and professional societies are
  necessary to support and stabilize professionalism

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ACADEMIC HEALTH CENTER

• The greatest challenge in improving the teaching
  of professionalism is to modify the internal
  culture of the academic health center so that it
  better reinforces the values that medical
  educators wish to impact.
• Ludmerer
• 1999

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• The profession of medicine is under siege. Our
  resistance must be professionalism.
• Harris
• 2000

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CONCLUSIONS

• I. Time honored characteristics of a profession
• Specialized education
• Autonomy to set standards
• Commitment to service

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CONCLUSIONS

• II. Profound changes in the delivery of health
  care have introduced real and significant
  challenges in regards to medical professionalism

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CONCLUSIONS

• III. Genuine medical professionalism is in peril

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CONCLUSIONS

• IV. The hidden curriculum must be recognized,
  discussed, and addressed

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CONCLUSIONS

• V. The 21st century demands a revitalization of
  medical professionalism which can and must be
  accomplished in our academic health centers
• HEREIN LIES OUR FUTURE!

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• 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.