|Year : 2014 | Volume
| Issue : 2 | Page : 119-122
Quest for medical professionalism in uncertain times
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||11-Nov-2014|
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. Quest for medical professionalism in uncertain times
. Arch Med Health Sci 2014;2:119-22
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
Is the practice of Medicine a science, an art, a trade, a craft, a business, a profession or a combination thereof? As far as I believe, it is a profession, an art based on the science of specialized knowledge; it is a 'calling' involving not only the practice of systematic, evidence-based knowledge, but that virtues trustworthiness, compassion, selfless service and altruism. It is a 'vow of service' that has a passion and a quest for healing with a 'confluence of interests' rather than a 'conflict of interests' and economic opportunism.
It is interesting to reflect on the evolution of professionalism in general. In the late 19th century society did recognize only three learned professions viz. Law, Medicine and Theology (Divinity). With the subsequent explosion of knowledge, information and technology, professionalism became increasingly democratized and has permeated all levels of society today. As far as Medicine is concerned, from the early 1900s until the 1950s, the physicians in the society had a dual role that of a healer and a professional, and this era was referred to as the 'Golden Age of Medicine'. With the dawn of the 'questioning society' in the 1960-70s, criticisms arose on the benefits of professionalism to society, societal shift in attitudes toward doctors, and the dissonance between ethics versus commercialism crept into the medical profession. Over the last 40-50 years, there has been an extraordinary transformation of the medical profession with the growing importance of governments, economic and technological forces, the corporatization of health care, and the shift to a 'medical marketplace' posing significant challenges and threats from within and outside. The better-informed community also began to ask for accountability, transparency and sound professional standards. Over the last few decades, these factors ultimately tarnished the image of a doctor and the levels of trust and respect that was once extended to the 'noble profession' substantially eroded.
What, then, if anything, distinguishes a profession from, say, a trade or craft? In this respect, I would stress on an 'etiquette-based medicine' approach, a multifaceted concept incorporating 'patient-centered professionalism', ethics and humanism. , Several bodies (The American Board of Internal Medicine, The Physician Charter, Royal College of Physicians of London's Working Party on Medical Professionalism, the King's Fund report, and the Picker Institute Europe) have projected numerous definitions. Albeit, the various definitions on professionalism, I do certainly recognize several commonalities, universal or core attributes governing the varying definitions of professionalism. Adopting 'cultural humility', I would not hesitate to stress that professionalism, being a complex multidimensional social construct (between the doctors, patient and public at large, society's expectations of medicine) is culture-sensitive. There are significant differences in professional behavior and humanistic attributes between the West, East and Arabian communities, and an area that is fertile for cross-cultural research studies that could pave the way for a future universal/global operational definition of Medical professionalism. Based on the complex evolution of our society, a sociologist would see beyond the moralistic point of view of the 'traditional professionalism perspective'. Thus a shift to 'new/renewed professionalism' construct did reorient the emphasis of medical practise from 'individuality' (the exclusivity of medical knowledge and skill to doctors), to one based on 'mutuality, egalitarianism, poly-professionalism and inter-professionalism'. This 'renewed professionalism' construct has taken into consideration not only the doctors' relationship with evidence-based systematic knowledge and patients, but also address the society, health care teams, various stakeholders, regulators and employers on a political, economic and social dimension.
"Vaidyo narayano harihi0", a Sanskrit sloka states that 'doctor' is a form of Lord Narayana who personifies the 'divine doctor' and their noble work. Quoting Kenneth M Ludmerer, a medical historian and educator, "Medicine is, at its center, a moral enterprise grounded in a covenant of trust. Today, this covenant is significantly threatened." Today, at the core of the heart of medical practice and its moral contract with society, I sadly acknowledge that genuine professionalism is indeed in peril. As a 'critical insider', being in this profession for the last three decades, there has been a significant shift of societal attitudes where physicians being criticized for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence. With the complexities of modern health care, medical professionalism has evolved from the old style medical paternalism to partnership, mutuality, managerialism, team professionalism, inter-professionalism and shared responsibility.
I feel that root cause of de-professionalization is very intricately interwoven, complex and multifactorial. These changes are due to the powerful influences of commercialization of health care, health insurance companies, escalation of health care costs, growing privatization and monetarization of medicine, the pressures for cost-effectiveness, transformation of health care to a 'profit-maximization model' and thus a 'health care industry'. Unprofessional relationship of the physician to multinational pharmaceutical industries, the consequences of globalization and the information revolution also contributed to changes in the doctor-patient relationship and the erosion of patient trust. Furthermore, the shift of decision-making power from physicians and patients to hospital managers and administrators resulted in the bureaucratization of doctoring. With the complex evolution of health care delivery set within a context of corporate interests, the physician's "sovereign profession" was threatened and doctors were reduced to the status of an employee. Thus, Medicine itself became increasingly fragmented; by specialty, by the interplay of various stakeholders, by practice and politically. Commercialism, commoditization of medicine, and consumerism has changed the patient-doctor relationship as something less than a fiduciary relationship.
Recognizing the increasing complexities of modern medicine, isn't it time for reinvigorating medical professionalism as a Neo-Hippocratic movement to spread the vision of a renewed 'professionalization model'? How can we restore medical professionalism to the heart of medical practice? In my opinion, the concept of 'traditional professionalism' needs to be re-interpreted as a dynamic concept of 'new/modern professionalism' that considers all issues of our complex and ever-changing moral enterprise of health care in the 21st century. Therefore, the efforts for re-professionalization must take into account the expectations of the society, society's expectations of medicine and the profession. The society should be reassured that physicians will be patient advocates, implement high standards of professionalism with greater stress on altruism, morality and virtue and the fiduciary duty to the patient. In order to restore the integrity of our profession during turbulent times, the profession of Medicine must be resurrected as a moral enterprise, fulfil its role of a healer, regain the loss of trust by society, re-establish its social contract, and actively re-dedicate to the principles of professionalism.
In India, and other countries, Traditional medicine (AYUSH in India) has entered the mainstream to compliment medicine and contribute to the healthcare delivery system. Furthermore, in our current enterprise of modern healthcare delivery, professional boundaries are blurred, and the growing democratisation of health care has led to polyprofesionalism, and thus the ethics of interprofessionalism and to refrain from professional rivalry. With respect to 'traditional healers', a recognised profession in India, there is a need for Integrative medicine and inter-professional 'cross talk' between the traditional and modern medicine, rather than to function as parallel systems.
How can the art, heart, and soul of medical professionalism be re-energised? It is sad to note that the culture of medical schools today, a cradle for nurturing and fostering professionalism and humanism, is far from ideal. There is a disappearance of the master clinician, lack of role models and loss of mentors in the culture of medicine today. It would not be wrong if I would state that the prevailing, current learning environment in India is not emblematic of the highest professional etiquette. Therefore, a critical step should be a penchant for teaching and fostering professionalism in medical schools. There is an absolute need to transform the clinical learning milieu and social environment of our medical schools to one that will be conducive to encourage 'professional socialization' through hidden curriculum and informal curriculum. Innovative teaching-learning methods through experiential learning, appreciative inquiry approach, teachers and educators as role models, and a curriculum for teaching ethical behavior in the doctor-patient relationship would certainly be a powerful influence to inculcate, reinvigorate medical professionalism, and ensure professional behavior for tomorrow's doctors. , However, I would not hesitate to state that 'teaching professionalism' is not only a daunting challenge but also a fertile ground for undertaking rigorous research.
I have comes across instances where brilliant graduates and doctors are plagued by the question "Do I really want to be in medicine? Is medicine something I really want to do?; Am I truly doing what I'm passionate about in life?; Do I love my work?; Do I have a passion for medicine?; Do I still find great happiness and satisfaction for taking care of people?" Does this relate to the personality profile of young doctors? Perhaps the answer lies in the quote by Aristotle "Educating the mind without educating the heart is no education at all", I stress the importance of student selection assessment for non cognitive attributes that may be predictive of future unprofessional behavior. This could be assessed by Medical College Admission Test and Grade Point Average scores, Personal Qualities Assessment tool, the Multiple Mini Interviews, Thematic Apperception Test, or the 16 Personality Factor Questionnaire. Reflecting from my travel through medicine, I would not hesitate to emphasize that the humanistic predispositions of new entrant medical students need to be nurtured in order to ensure that the 'developing physician' would manifest the attributes of medical professionalism.
I see a vital quintessence vanishing from 'heart, art and soul' of medicine; it's not compassionate, and the art of healing is lost. Medicine is increasingly fragmented and dehumanised. Doctors no longer see a distinctive person, instead as a set of deranged organ systems based reductionist approach. The distressed patient "whole" is absent in this equation of healing. How do we undertake this moral enterprise of humanizing our modern medicine? I do not see a solution in the evolving definitions of professionalism since it portrays a reductionist concept. Humanism should be central to professionalism. I vehemently believe, as humans, and 'being human', we need to galvanise professionalism with humanism. We need to distinguish professionalism from humanism, reduce the conflicts between altruism and self-interests. We need to produce humanistic and virtuous physicians enshrined with the code of professionalism, and I believe this will be able to overcome the dehumanizing aspects of modern healthcare. Here, I reflect on a quote that describes a 'good teacher', 'A good teacher is like a candle - it consumes itself to light the way for others' which reflects altruism, a humanistic attribute. In our current practise of medicine today, there is growing visible tension between the two opposing conceptions of altruism and self-interests, and I would stress on the need to build bridges to narrow this gap to protect and preserve the moral credibility of our whole medical enterprise. Does the medical profession entail effacement of physician's self interest, and if so, to what degree? Is some degree of altruism a moral obligation, or is nonmaleficence the 'line of control' of the doctor's mandatory beneficence? It is extremely crucial to have a curriculum in medical schools for both these dual values; because professionalism (parochialism) does not necessarily embody humanism (universalism), and I am an advocate for unifying the science, art, heart and soul of our medical practise by linking professionalism, and professional ethics to humanism.
Lastly, if professionalism can be 'taught', can it be measured in a holistic manner as formative tools within the larger process of professional education? Since it is a 'slippery and qualitative concept' and encompasses many different and varied components and behavioral domains of humanism, altruism, compassion, integrity, accountability, and the pursuit of excellence; robust objective measures of professionalism remains elusive. However, this difficult territory of assessing professionalism could be tackled using the Miller's pyramid, workplace based assessment methods and a multidimensional approach. This will include assessment of knowledge, attitudes, and practice of professionalism; peer assessments, direct observations, or patient evaluations; assessment of student behaviors and analysis of student narratives on critical incidents (narrative based professionalism). Furthermore, various quantitative tools have also been developed for objective proxy measures of professionalism. These special instruments include Conscientious Index, Clinical Conscientious Index & Professionalism Index; Nijmegen Professional Scale, Professionalism-Mini Evaluation Exercise, and Situational Judgment Test. I would stress that the target of such 'measures' is to identify students/residents in need of remediation (remediating professionalism).
Being a conscientious physician, I would reiterate that values of medical professionalism should not only be promoted, developed and taught as a mandate in the formal medical curriculum at the undergraduate and postgraduate training levels, but also modeled within the very fabric, internal culture and social milieu of medical schools, hospitals and health care systems. Research into professionalism is in its infancy and this burgeoning arena is vital, needs to grow and should be encouraged. It is of paramount importance that each individual physician should protect, enhance, and promote professionalism 'soft skills' and collective human dignity in the enterprise of health care. The glass would indeed be half empty, if I don't stress on other challenging areas in India. This entails physician self regulation (through the governance of Medical Council of India), maintenance of professional competence, recertification, identification of problem physicians and regulation by professional ethics bodies in India. These are the challenges in the quest for upholding the integrity of medical professionalism and safeguarding its obligations to the society. With a deep seated conviction, I emphasize that medical professionalism and the moral enterprise of healthcare must be linked to humanism which would guarantee the dual roles of a 'medical professional' and 'healer'.
"The profession of medicine is under siege. Our resistance must be professionalism."
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