Transcript The Healer and The Professional in Society

The Healer and The
Professional in Society
“ Neither economic incentives, nor
technology, nor administrative control
has proved an effective surrogate for the
commitment to integrity evoked in the
ideal of professionalism ”
Sullivan, 1995
General Perceptions
We live in a time of unprecedented change.
We live in a questioning society.
Professions and medicine have lost status.
We will not return to the golden period.
The future will depend in part on how medicine
responds.
Professionalism is the key to public trust.
The Physician Has Two Roles
• Healer
• Professional
The two roles
•Served simultaneously.
•Analyzed separately.
Professionalism and Medicine
The concept of the healer
The concept of the professional
Antiquity
Middle ages
“Learned professions”
clergy, law, medicine
Hippocrates
technology
“curing”
The Present
Code of
Ethics
Science
1850: Legislation
1900: University linkage
The Present
Physician
Healer
Caring and compassion
Insight
Openness
Respect for the
healing function
Respect patient
dignity and
autonomy
Presence
Professional
Competence
Commitment
Confidentiality
Altruism
Integrity and honesty
Morality and ethics
Responsibility to the
profession
Autonomy
Self-regulation
Responsibility
to society
Team work
The Primary Role is that
of the Healer
Medicine’s Values Are
Derived From Both The
Healer and the Professional
To Heal
To make whole or sound in bodily
conditions; to free from disease or ailment,
to restore to health or soundness.
Oxford English Dictionary
Definition
Profession
“An occupation whose core element is work based upon the mastery of a
complex body of knowledge and skills. It is a vocation in which
knowledge of some department of science or learning or the practice of
an art founded upon it is used in the service of others. Its members are
governed by codes of ethics and profess a commitment to competence,
integrity and morality, altruism, and to the promotion of the public good
within their domain. These commitments form the basis of a social
contract between a profession and society, which in return grants the
profession a monopoly over the use of its knowledge base, the right to
considerable autonomy in practice and the privilege of self-regulation.
Professions and their members are accountable to those served and to
society.”
Derived from the Oxford English
Dictionary and the Literature on Professionalism
In Press, “Teaching and Learning in Medicine”
Society uses the concept of the
professional as a means of
organizing the delivery of complex
services which it requires,
including that of the healer.
“The Professional Model”
Other Models are Available
• Bureaucratic
• Free Market
>
none pure
Neither Share the Values of the Healer
• The social contract in health care
hinges on professionalism.
• It serves as the basis for the
expectations of both medicine
and society.
This Contract Has Always Been
•Implicit (largely unwritten)
•Evolving (being constantly
renegotiated)
The Social Contract
Society
Medicine
•
fulfill the role of the healer
• guaranteed competence
• altruistic service
• morality and integrity
• promotion of the public
good
• openness
• accountability
•
•
•
•
•
•
monopoly
autonomy
trust and respect
self-regulation
adequate resources
status and rewards
TRUST


financial
non-financial
To Preserve Its Traditional Values,
Medicine Must Understand:
•
•
•
•
The role of the healer
The role of the professional
Their interrelationship
The obligations necessary to maintain
professional status
Characteristics of the Medical Profession
• Characteristics are linked to obligations.
• Obligations are  individual
 collective
Characteristics and Obligations of a Profession
Characteristic
 Specialized
knowledge
and skills
not easily understood
Obligation
• maintain competence
• teach
students and trainees
patients
public
• protect integrity of
knowledge and its use
• support research
• applies both individually
and collectively
Characteristics and Obligations of a Profession
Characteristic
 Commitment
to Service
to individual patients
to society
Obligation
• Altruism
individual
collective
• Fundamental to trust in the individual and the profession
• Conflicts of Interest
• Generational issue - lifestyle
Characteristics and Obligations of a Profession
Characteristic
 Morality
 Honesty
 Integrity
Obligation
• be governed by
professional and ethical
standards of conduct at all
times
• applies both individually
and collectively
Characteristics and Obligations of a Profession
Characteristic
 codes
of ethics
Obligation
• individual

to know and be governed
by the appropriate codes
• collective

develop and maintain
codes
Characteristics and Obligations of a Profession
Characteristic
Obligation
 Autonomy
• use autonomy in practice
to best serve the patient.
• use autonomy wisely to
collective
best serve society.
• resist restrictions of autonomy which interfere with ability
to best serve patients and society.
individual
Characteristics and Obligations of a Profession
Characteristic
 Licensing
Bodies and
Professional Associations
• state sanctioned authority
• collegiality
• major self-regulatory role
set and maintain standards
discipline
• advise public
Obligation (collective)
• demonstrate morality and
virtue
• guarantee competence
• be open and transparent
• be governed by an
institutional code
Licensing Bodies and Professional Associations
MUST MANAGE CONFLICT OF ROLES
altruism vs self-interest
public good vs union function
POTENTIAL TO PROMOTE OR
SUBVERT THE IMAGE OF MEDICINE
Characteristics and Obligations of a Profession
Characteristic
 Self-Regulation
Obligation (individual)
• maintain competence
• participate in and submit to
the process of self regulation
• support professional
associations and regulatory
bodies
• ensure their integrity
Listing characteristics seems to make
them equal.
They Are Not
Essential Elements
• Specialized knowledge
Science
Art
• Service to others
• Morality
Literature
• Early
- supportive of professionalism
- recognized tension between altruism
and self-interest
• 60’s and 70’s
- very critical
- documented medicine’s failures
- questioned relevance to society
Literature - 80’s to present
Reflects the New Reality
“Countervailing Forces”
• dominance of state and/or corporate sector
influence of medicine
“Accounting Logic”
• value systems of the state and/or corporate sector
values of professionalism in health care
Literature - 80’s to present
• Because of society’s need for the healer, physicians will continue
to have status and to be reasonably well compensated whether
they are independent practitioners or employees.
• Reasonable autonomy will be preserved because neither the state
or the market place wish to be responsible for “life or death”
issues.
• Now supports a renewed “professional model”.
“civic professionalism” - Sullivan
“ reborn professionalism” - Freidson
“ reinvented ” professionalism - Stevens
• uncertain as to how much influence the professions will regain.
“In spite of its failings,
professionalism is based on the real
character of certain services - it is not
a clever invention of selfish minds”.
Marshall, 1939
• The social scientists have returned
to faith in the value of professions.
• It is critically important that society
also support the professional model.
Optimism Can Be Justified
• The public is dissatisfied.
• Medicine retains more trust than the state or corporate
sector.
• The state and/or corporate sector control the market place.
– they and not medicine are blamed for defects in
the system.
• Health is a political issue - public good/right.
• The political process will lead to change.
• The principle cause for optimism is society’s need for the
healer.
Loss of Influence
Opportunity to rebuild trust
The Social Contract is
Being Re-Negotiated
Legitimate worries and
concerns on both sides
Negotiations
• Can involve virtually all stakeholders with an
interest in health, and take place in many settings.
• Influence on negotiations can be either direct or
indirect and lead to minor or major changes.
• Medicine is no longer the dominant player - but it
is at the table.
Society’s Needs and Expectations
The healer working as a professional
– using knowledge to heal and/or cure
– guaranteeing competence
–working in partnership with patients
– demonstrating morality and virtue
– being accountable
Accountability
Traditional
• To patients and colleagues
• For advice on public policy
• Self-regulation and discipline
• There have been high-profile failures in the area of
self-regulation.
• These failures led to trust and a consequent
inability to influence the newer levels of
accountability now demanded.
PROFESSIONS MUST SELF-REGULATE
Accountability - New
• Economic (to payors)
corporate
state
• Political (to wider society)
impact on resources
population health
The Professions’ Needs and
Expectations
1) Deserve trust and respect despite some failings.
2) Expertise should be recognized and used.
3) Autonomy sufficient to act in best interests of patients and
society.
4) Regulatory procedures that are reasonable and validated.
5) Adequate resources.
6) A health care system which promotes (and does not subvert)
those values which society wishes in its healers - caring,
altruism, courtesy and competence.
What Must Medicine Do?
Fulfill the Role of Healer
What Should Medicine Do?
Address Principle Causes of Loss of Trust
• perception of
altruism
• failure to self-regulate
• behavior of some of medicine’s institutions
• lack of a single voice representing medicine
What Should Medicine Do?
Individual/Collective Responsibility
• Understand professionalism.
teach and evaluate it at all levels
• Understand and meet the obligations needed
to sustain the professional model.
 altruism
 integrity
 self-regulation
 accountability
Who Speaks for Medicine?
• AMA
• Other
BMA
CMA
Those Negotiating on Behalf of the Profession
• Must recognize and deal with the conflict of
roles.
• Must place societal needs above those of the
profession.
Those Negotiating on Behalf of the Profession
• Must look for partners
» patients
» advocacy groups
» health professionals
» ? government
» ? corporate sector
» media
» others
Those Negotiating on Behalf of the Profession
Must negotiate a social contract that supports the attributes and
values of the healer.
• Rewards quality rather than volume.
• Rewards professional and penalizes unprofessional behavior.
• Issues to consider:
– financial incentives/disincentives - individual
- institutional
– use of competition for cost control
– regulation of conflicts of interest
– regulation of marketing of products
Convince Society of the Advantages
of the Professional Model
“The International Charter”
“American College of Surgeons
Code of Professional Conduct"
Public Policy Must Support
The Professional Model
“The most important problem
for the future of professionalism is
neither economic nor structural but
cultural and ideological. The most
important problem is its soul”
Freidson, 2001