Maintaining our professionalism in the face of change
By C. Anderson Hedberg, FACP
The major medical organizations that help define us as physicians are placing a new emphasis on the concept of professionalism.
In 1999, the Accreditation Council for Graduate Medical Education identified six core competencies that residents in training must master. They are patient care; medical knowledge; practice-based learning and improvement; interpersonal skills and communication; systems-based practice—and professionalism.
Soon after, the American Board of Medical Specialties adopted those competencies as the basis of maintenance of certification for all its member boards. The residency review committee for internal medicine now uses them as its framework for evaluating training programs, while the American Board of Internal Medicine (ABIM) has made these six the basis for its certification and recertification processes.
'A working definition'
Many different definitions of professionalism have been written since Hippocrates laid out his version of professional principles. While specific definitions have changed, the concept of professionalism has long stood for professional integrity and service. That concept has been an essential vehicle for expressing the highest ethical standards of our profession.
What are the standards that make up professionalism? Here is one concise modern definition drafted by P. Preston Reynolds, FACP, and published in the April 1, 1994, issue of Annals of Internal Medicine:
"As a working definition, medical professionalism is a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one's own. Honesty and integrity are values essential to medical professionalism. The professional physician has an attitude of humility and accountability to patients, colleagues, and society. Professional behaviors include a nonjudgmental and respectful approach to patients, the pursuit of specialized knowledge and skill with a commitment to excellence and life-long competency, and a collegial and cooperative approach to working with members of a healthcare team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of physicians to fulfill the goals set forth by the profession and the public. In exchange for putting the interests of the patient and public first, physicians are accorded trust, respect, and the confidentiality of patients."
In the years since Dr. Reynolds penned her working definition, the practice environment has continued to see dramatic changes. Those changes began in the last third of the 20th century—and they continue to accelerate even now.
What was once a fee-for-service cottage industry involving two people—a doctor and patient—has become a bewilderingly complex system that now includes purchasers, mammoth for-profit insurance companies, government payers and regulators, international pharmaceutical companies, and networks of hospital systems.
A mixture of free-market forces and government regulations now govern our reimbursement, while health care costs continue to rise and physician autonomy continues to be squeezed.
These changes, known as the "corporatization" of American medicine, have introduced a bottom-line mentality to medical care. Some of us worry that patients have become a commodity, one that's being rushed through our health care system by physicians who have little time to tend to humanistic needs. At the same time, serious health system concerns are becoming more acute as the number of uninsured and underinsured patients continues to grow, safety problems are increasingly evident, and studies show that the quality of American health care is uneven, with both under- and overuse of tests and therapies.
In the face of these changes, many of us are concerned that our professionalism is being threatened. And many of us are taking steps to continuously renew and emphasize professionalism for the benefit of our fellow students, residents and practitioners.
Staying the course
How can we maintain a robust moral compass in the midst of all this? Most medical students have a strong sense of right and wrong, but given our present circumstances, the concept of professionalism must be taught through didactic interactive sessions, case studies and role modeling. Physicians who teach and/or practice should keep enriching their awareness of professionalism throughout their careers, and act as role models for medicine's next generation.
Given our present circumstances, the concept of professionalism must be taught through didactic interactive sessions, case studies and role modeling.
Over the last several years, internal medicine has made two major efforts to boost professionalism. A decade ago, the ABIM began "Project Professionalism," producing an engaging booklet for residents. It includes concise definitions and objectives of professionalism, along with vignettes, evaluation tools and an excellent bibliography. (The booklet is online.) For many years, I found "Project Professionalism" to be an extremely useful tool for interactive sessions that I taught at Rush University Medical School.
The second major effort was an international one. The ACP Foundation, the ABIM Foundation and the European Federation of Internal Medicine jointly authored the "Medical Professionalism in the New Millennium: A Physician Charter," published in the Feb. 5, 2002, issue of Annals of Internal Medicine. Booklets containing the charter can be ordered from firstname.lastname@example.org.
Stating that professionalism is the basis of medicine's contract with society, the charter identifies the three fundamental principles of professionalism as the primacy of patient welfare, patient autonomy and social justice.
It then details 10 commitments that provide excellent guidance in how to maintain professionalism. (See "A charter's 10 commitments.") They represent an appropriate framework for us to use when examining different courses of action when knotty medical dilemmas arise.
Knowing medicine's ethical foundations is another key component in professionalism. ACP's "Ethics Manual, Fifth Edition," published in the April 5, 2005 issue of Annals of Internal Medicine, is a practical and detailed guide for a wide spectrum of commonly encountered ethical issues. Topics include the doctor-patient relationship, relations with health care plans, confidentiality, informed consent, reproductive and genetic issues, end-of-life planning, organ transplantation, euthanasia, research ethics and professional responsibilities.
As it was in ancient times, we can serve the best interest of our patients and our society only by keeping the concepts of professionalism at the forefront of our practice. Fostering professionalism will allow us to nurture the trust we need in our relationship with patients, even as we face new challenges.
In 2002, the "Medical Professionalism in the New Millennium: A Physician Charter" project spelled out 10 commitments that inform medical professionalism. Those commitments:
- Professional competence
- Honesty with patients
- Patient confidentiality
- Maintaining appropriate relations with patients
- Improving quality of care
- Improving access to care
- Just distribution of resources
- Scientific knowledge
- Maintaining trust by managing conflicts of interest
- Professional responsibilities
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