Transcript MEDICAL PROFESSIONALISM: PERILOUS TIMES

MEDICAL
PROFESSIONALISM IN
st
THE 21 CENTURY:
IS THERE A NEED FOR
REVITALIZATION?
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
 Today at the dawn of a new
century, genuine medical
professionalism is in peril
 Trade or profession?
 Market economy a primary
diminishing factor
“Medicine is, at its center, a moral
enterprise grounded in a covenant
of trust. Today, this covenant is
significantly threatened.”
Ludmerer
MEDICAL
PROFESSIONALISM
• Definitions
• Evolution
•Concerns
•Revitalization
•Conclusions
DEFINITIONS
A PROFESSION
“A profession…is 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
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
SEVEN PILLARS OF A
PROFESSION
1.
2.
3.
Technical skill and
craftsmanship,
renewed by
continuing education
A sense of social
responsibility
A knowledge of
history
4. A knowledge of
literature and the
arts
5. Personal integrity
6. Faith in the meaning
and value of life
7. The grace of humility
E.P. Scarlett
THE PROFESSIONAL
 Patients first
 Service/public leadership
 Nonjudgmental care
 Collaboration
 Lifelong learning
THE NON-PROFESSIONAL
 Dishonest
 Lacks
 Greedy
interpersonal
skills
 Conflict of
interest
 Self-serving
 Impaired
 Abuses power
EVOLUTION OF THE
PROFESSIONS
EVOLUTION OF THE
PROFESSIONS
 The Hippocratic Oath
- A vow of service
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
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
THE PROFESSION OF
MEDICINE
Ideal
Foundational
Value
Evidence-based
Truth/Science
Caring, healing
Curing
Open heart/mind
Error-free
Analytic
Self-sacrificing
Accepting, Empathetic
Right action
Reality
Uncertainty
Risk-harming
Arrogant, unmoved
Mistake-prone
Reflective
Hassled, knee-jerk
Altruistic
Avaricious
-Inui
THE PROFESSIONS AND
THE UNIVERSITY
 Standardization
 Professional degree
th
20
CENTURY
 Post WWII – many critics
 Self interest
 Monopolistic
 Personal gain
“No longer seen as working quietly for
the public good the American medical
profession took on a sinister, even antisocial characteristic, in its role in the
culture at large. Some influential
critics also revised the profession’s
history from a glorious narrative
success to a more ominous tale of
hubris.”
Rosemary Stevens
21st CENTURY
CONCERNS
THE NEW CENTURY
 Specialization of medicine
 Faculty reward systems
Publish or perish
 Generational gaps
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
THE DOCTOR’S DILEMMA
Patient-Centered
 Advocates for
patients
 Optimal effective
care
Marketplace
 Proxies for the plan
 Low cost care
Benson
THE DOCTOR’S DILEMMA
Patient-Centered
 Managed care
 Concern for
individual
 Bedside rationing
Marketplace
 Managed cost
 “Distributive ethic”
 Centralized rule-
based rationing
Benson
 Profound influence of a market
economy with perverse financial
incentives threatens to reduce the
medical profession to a lowest
common denominator
 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!
“Failure to affirm the primacy of the
patients’ welfare will result in a
loss of the public trust and
medicine’s slide from a revered
profession to an occupation
populated with technical experts”
Hafferty
THE NEW CENTURY
 Gradual disintegration of
education community
 Disappearance of the master
clinician
 Loss of role models
 Loss of mentors
THE APPRENTICESHIP OF
PROFESSIONALISM
 Acquisition of a knowledge base
 Acquisition of skills
 Acquisition of an understanding of
ethical standards, social roles and
responsibilities
CURRICULUM
 Formal – what we say
 Hidden – what we do
FORMAL CURRICULUM
 Empathy
 Compassion
 Altruism
}
What we
say
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
HIDDEN CURRICULUM
 Weariness
 Strong distrust of emotions
 Failure of communication
HIDDEN CURRICULUM
 Ethic of detachment
 Self-interest
 Over objectivity
 CYNICISM
JOURNAL ARTICLES
1. “Burnout and Self-Reported Patient Care
in an Internal Medicine Residency
Program”
2. “Stress in Medical Residency: Status Quo
After a Decade of Reform?”
3. “Who is sicker: Patients – or Residents?
Residents’ Distress and the Care of
Patients”
4. “Heeding the Plea to Deal with Resident
Stress”
Annals of Internal Medicine
March 5, 2002
HIDDEN CURRICULUM
 2nd set of beliefs - as students,
residents wend their ways through
years of education they gradually
adopt the medical culture and it’s
value system as their own
abandoning traditional values.
ACADEMIC HEALTH
CENTER
“Moral tone frequently subverts
rather than supports the
development of good professional
morals.”
Huddle
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
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
“Today’s culture of medicine is
hostile to altruism, compassion,
integrity, fidelity, and selfeffacement”
Coulehan
REVITALIZATION
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
THE GENERATIONS
Veterans
Baby
Boomers
Cuspers
Busters
1922-43
1944-59
1960-68
1969-79
Gen Nexters
1980-
“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
 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
REVITALIZING
PROFESSIONALISM
 Faculty development critical
 System of evaluation
 Professional tone and awareness
set from the top!
 Strong institutional support
REVITALIZING
PROFESSIONALISM
 Cognitive base
 Experiential learning
 Continuity
 Role Modeling
 Mentorship
“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
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 society’s
expectations of them as future
practitioners.”
Whitcomb
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
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
“The profession of medicine is under
siege. Our resistance must be
professionalism.”
Harris
2000
CONCLUSIONS
I. Time honored characteristics of a
profession
 Specialized education
 Autonomy to set standards
 Commitment to service
CONCLUSIONS
II. Profound changes in the
delivery of health care have
introduced real and significant
challenges in regards to
medical professionalism
CONCLUSIONS
III. Genuine medical
professionalism is in peril
CONCLUSIONS
IV. The hidden curriculum must be
recognized, discussed, and
addressed
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!
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.