Medical Humanities

Professionalism: Use It or Lose It

Jock Murray, MD

About the Author

T. Jock Murray is professor emeritus and the former dean of Dalhousie Medical School and former chairman of the Board of Regents of the American College of Physicians. He continues his clinical and research work in multiple sclerosis and writes on medical history and humanities.

There has been increasing concern about the concept of professionalism in the past few years, voiced in the press, in medical journals, and in university circles. The nature of professionalism has changed over time as our responsibilities to our patients and to society have changed. Centuries ago, it was based on competence; medicine was a skilled trade providing a service to those who could afford it. Later, an element of altruism shaped professionalism so that the physician’s knowledge and skill served those in need. In the past century, we have added the concepts of nobility of service and the democratization of medicine, which respects the autonomy of our patients.

However, there are widespread threats to this concept. The de-professionalization of medicine has been evident for some time, and physicians are becoming disheartened. Polls over the past decade have noted that many physicians would not recommend their children, or any young person, go into medicine. A profession in which many members would not encourage the next generation to follow them is a profession in serious trouble.

Many have commented that physicians have developed a siege mentality, worn down by the “hassle factor,” fearing the Barbarians at the gate, worried about marginalization of physicians, and bruised by intrusion into their decisions about patients. This is not paranoia.

There is an increasing desire by other parties to have physicians function as skilled employees rather than as professionals. There are people outside the profession who want to redefine our role of physicians in a way that serves their interests. There are increasing external controls over the profession and its members. There is a growing atmosphere of complaint and malpractice. And there are increasing incentives that reward physicians for serving the “system” but in ways that may not best serve our patients.

The erosion of professionalism is coupled with a public attitude that sees us in a less positive light. Some say the peak of the Golden Age of Medicine was in the 1960s. At that time, the image of the doctor was the kindly, caring physician who had new and very powerful medicines in his black bag, eager to serve his patients and his community. On TV, physicians were represented by the idealistic Dr. Kildare and Dr. Marcus Welby.

What do we have today? As the public becomes more cynical about the role of physicians and the profession, with the backdrop of corporate medicine, competing insurance companies, de-insuring tactics, rising health costs, the uninsured and malpractice, how are doctors portrayed?

We have the TV medical dramas ER, House, Nip/Tuck, Scrubs, and Grey’s Anatomy, where physicians are seen as self-absorbed and egotistical, more concerned with their own problems than those of the patients; moody, rude, argumentative, uncooperative, and disrespectful, not only to each other but to the patients as well. They argue out their impassioned lives, prejudices, and conflicts in front of patients – almost as if they were not there. Such unprofessional behaviour would clearly be unacceptable in real life and would prompt official complaints and very negative trainee evaluations. It might make good TV drama, but it is an awful display of professionalism. In addition, the public see on Nip/Tuck technologically adept and surgically skilled but entrepreneurial plastic surgeons whose motivation seems more financial than esthetic.

And what do you make of Dr. House? Here we see a new and disturbing image of the modern doctor. Dr. House is a seriously flawed physician, who seems to enthrall the public by his Sherlock Holmesian sleuthing while lashing out at staff, belittling students, and cynically snapping questions at patients. As I leave for the hospital in the morning, I pass a billboard for House that has him dishevelled and scruffy, saying to a patient with serious liver disease, “You’re orange, you moron!”

Unfortunately, at a time when the public is losing faith, they see every night on their TV examples of doctors lacking professionalism, acting in a manner that suggests they are not worthy of trust, and who need to be brought under control. I realize that this is just TV drama, but it reflects a public perception and it, in turn, reinforces the idea that professionalism, if not terminally ill, is sadly in need of medical attention.

This increasingly cynical public attitude toward the medical establishment is paradoxical. At a time when medicine and physicians can do so much more, when medical science has brought such remarkable advances, the trust and faith in all of this has waned. At a time when medical schools are spending many more hours on communication skills, ethics, and humanistic attitudes, we are seen as more distant and self-serving.

The concept of professionalism involves fundamental principles and responsibilities. First, you must be competent. A physician must be competent to offer the appropriate care to patients, and this competence is related to clinical skills, knowledge, technical ability, humanistic attitudes, and communication skills. But competence is not enough.

Primacy of patient welfare is the moral core of professionalism. You owe your first duty to your patients. Not to yourself, your practice, or your hospital. As advocates for your patients, you must speak out and act if there are decisions being made by agencies that are clearly not in the interests of good patient care. The old term fiduciary responsibility indicated that medical decisions must always be in the interest of the patient. This also respects patient autonomy and the rights of patients in the health care system, and in your interactions with them.

Another core concept is social justice. This means we are not just dedicated to the individual patient, but we have responsibility to all patients, and to society, as part of our social contract.

Doctors don’t mean to be belligerent or uncooperative in our defense of professionalism. We can be good players, we can be collaborative, and we can be effective in health care change and in making organizations effective and successful. We can work effectively in many different structures and settings, whether in academic health care systems, government agencies, or non-for-profit organizations. But we must always have in our minds that we are professionals, and we must always act in the interests of our patients.

I want to emphasize that a “call to professionalism” is not “resistance to change.” It is not a veiled attempt to protect the power and status of physicians. It is not an endeavour to return to another age characterized by elitism and self-interest, the “good old days.” It is a call to practise the best medicine in the best interests of our patients.

It is our responsibility as individual physicians to defend professionalism. Those who would like to alter and undermine professionalism are not bad people – they have a different professional and ethical system, and we are fooling ourselves if we think we can make them adopt our ethical system and espouse the fundamental principles of medical professionalism. Our fundamental concepts are appropriate to medicine, just as the ethical system of business is appropriate for business, and the ethical systems of the legal community, and the military, and the police are appropriate for their constituencies. It is when one group with an ethical system becomes involved in – or, worse still, takes charge of – another group that we have difficulty. That’s why the professional and ethical system of medicine would not work for the law, governments are not good at running business, the military should not be running governments, and, dare I say it, business should not be running medicine.

Business interests and the ethics that govern them are increasingly prevalent in medical practice today. It can be good business to be conscious of patient care and professionalism, but it is not their goal. Most would not be in the complex area of patient care if it were not profitable. In fact, from a purely business point of view, professionalism and the primacy of patient care are complex, frustrating, and diverting from goals and agendas that relate to boards of directors, shareholders, bottom lines, and profits.

But we can work together. We must first recognize and respect the ethical system and goals and professional ethics of each other and not delude ourselves that they are the same. We are not going to change the ethic of business to that of medicine, or vice versa.

Henry Kissinger talked about the way things were negotiated in the world, and about an American model and a European model. The American model was to have everyone sit around the table to hammer things out until everyone agreed and thought the same. The European model was to recognize that the French would always be the French, the English the English, the Germans the Germans, and so on. They were never going to think the same. So the approach was to recognize that fact and then see how they could still work together. In the complex world of health care, involving medicine, other health professions, government, business-oriented administrators, corporations, the pharmaceutical industry, and so many others, we need a European model that recognizes the different ethical systems and goals of each other, and reaches a consensus. If things continue as they are, however, the business ethic will try to erode further the concept of medical professionalism as being a hindrance to the smooth operation of a profitable business.

It is in the interest of the patients we are privileged to serve that we defend medical professionalism. But do we understand it well enough? I’m concerned that if I stopped a medical student, resident, or practising internist and asked if he or she believed that professionalism was a fundamental belief and a sacred covenant with patients, I would hope the answer would be “Absolutely!” But if I then asked for a definition of professionalism, there might be some shuffling and hesitation.

I see three major steps in the call to professionalism. Firstly, our universities and medical colleges need to recognize the importance of such a fundamental issue. Secondly, doctors need to know the concepts of professionalism and act these out in our lives, our practices, and our discussions. We should all be able to list and discuss the fundamental principles of professionalism, the responsibilities and commitments, and have them burned into our heads and hearts. We are able to remember the 12 cranial nerves, the 15 major causes of fatigue, and the 26 major causes of fever of unknown origin, so surely we can remember the fundamental principles and responsibilities on which professionalism is based, when they are central to our role as physicians. We can be forgiven for not remembering the 40 different causes of headache, but not for being unaware of the elements that make us medical professionals.

And not just list them – we must know their meaning and think of them when in discussions about medicine and decisions about patient care, in meetings and committees in our hospitals, in our medical organizations, and having coffee with others in our hospitals and clinics and communities. It is not enough to have a parchment defining professionalism nailed on the wall beside the AMA Code of Ethics, or added to the curriculum as a lecture some afternoon, between the lectures on chronic obstructive lung disease and cirrhosis. It has to be a living thing in the profession and in our educational philosophy.

If we want professionalism to flourish, we must have physicians everywhere living out the concepts of professionalism in their daily lives and practices. We must be conscious that every day, every moment, we are role models for future physicians and for what professionalism is all about. Role models have great influence. If we do it correctly, students will emulate us for the rest of their lives. If we do it incorrectly, they will copy our bad habits and teach them to the next generation.

Thirdly, we need to incorporate these principles into our educational approaches, our admission processes, and the experience in all years of medical training. We should look more diligently than we have to the admission process that selects the next generation of physicians. We often say we don’t know how to select the right kind of person, just the ones with the highest marks, but I am reminded of a senior physician who said, “I could select for those qualities if I could take the student with me for a weekend in my canoe. I could then see what they were made of.”

So let’s buy some canoes! I’m serious. If that’s the way to select the best future physicians for their personalities, attitudes, and qualities, then let’s buy some canoes. In some Chinese medical schools, the prospective students must work for a year as low-level workers in a hospital before applying to medicine so that they can see what they are made of.

You may smile at the idea of medical schools putting in large orders to L.L.Bean for canoes, but if not canoes, what? We have not spent enough time on the admission process. Despite attempts to change and broaden the process, it still really guarantees that we admit the intellectually brightest young people who have attained scholastic excellence. But the person in the street knows that the brightest people don’t necessarily make the best doctors. I think we are too slow in picking up on something everyone else seems to know.

When I became dean of Medicine some 20 years ago, I first wanted to revamp our admission requirements. I knew we wouldn’t take Mother Theresa unless she had organic chemistry and had gotten top grades. We made what were dramatic changes for our faculty, but the public instantly understood, and we saw results.

So, my message today is simple. We have a renewed definition of medical professionalism. Now it is up to each of us as individual physicians to know and practise our medical professionalism. If we don’t know the concepts of professionalism, we will not be able to defend them, and we will see the elements of our professionalism whittled and negotiated away.

If we don’t use it, we will lose it.

Article citation: Murray J. Professionalism:Use it or lose it. Can J Gen Intern Med 2007;2(4):33-35