MEDICAL PROFESSIONALISM IN THE 21 st CENTURY: IS THERE A NEED FOR REVITALIZATION?

1. MEDICAL PROFESSIONALISM IN THE 21st CENTURY:IS THERE A NEED FOR REVITALIZATION?

2. 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

3. Today at the dawn of a new century, genuine medical professionalism is in peril • Trade or profession? • Market economy a primary diminishing factor

4. “Medicine is, at its center, a moral enterprise grounded in a covenant of trust. Today, this covenant is significantly threatened.” Ludmerer

5. MEDICAL PROFESSIONALISM • Definitions • Evolution • Concerns • Revitalization • Conclusions

6. DEFINITIONS

7. 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

8. 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

9. Technical skill and craftsmanship, renewed by continuing education A sense of social responsibility A knowledge of history A knowledge of literature and the arts Personal integrity Faith in the meaning and value of life The grace of humility E.P. Scarlett SEVEN PILLARS OF A PROFESSION

10. THE PROFESSIONAL • Patients first • Service/public leadership • Nonjudgmental care • Collaboration • Lifelong learning

11. Dishonest Greedy Impaired Abuses power Lacks interpersonal skills Conflict of interest Self-serving THE NON-PROFESSIONAL

12. EVOLUTION OF THE PROFESSIONS

13. EVOLUTION OF THEPROFESSIONS • The Hippocratic Oath - A vow of service

14. EVOLUTION OF THEPROFESSIONS • 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

15. 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

16. THE PROFESSION OF MEDICINE -Inui

17. THE PROFESSIONS AND THE UNIVERSITY • Standardization • Professional degree

18. 20th CENTURY • Post WWII – many critics • Self interest • Monopolistic • Personal gain

19. “No longer seen as working quietly for the public good the American medical profession took on a sinister, even anti-social 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

20. 21st CENTURY CONCERNS

21. THE NEW CENTURY • Specialization of medicine • Faculty reward systems Publish or perish • Generational gaps

22. 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

23. Patient-Centered Advocates for patients Optimal effective care Marketplace Proxies for the plan Low cost care Benson THE DOCTOR’S DILEMMA

24. Patient-Centered Managed care Concern for individual Bedside rationing Marketplace Managed cost “Distributive ethic” Centralized rule-based rationing Benson THE DOCTOR’S DILEMMA

25. Profound influence of a market economy with perverse financial incentives threatens to reduce the medical profession to a lowest common denominator

26. 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!

27. “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

28. THE NEW CENTURY • Gradual disintegration of education community • Disappearance of the master clinician • Loss of role models • Loss of mentors

29. THE APPRENTICESHIP OFPROFESSIONALISM • Acquisition of a knowledge base • Acquisition of skills • Acquisition of an understanding of ethical standards, social roles and responsibilities

30. CURRICULUM • Formal – what we say • Hidden – what we do

31. FORMAL CURRICULUM } • Empathy • Compassion • Altruism What we say

32. 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

33. HIDDEN CURRICULUM • Weariness • Strong distrust of emotions • Failure of communication

34. HIDDEN CURRICULUM • Ethic of detachment • Self-interest • Over objectivity • CYNICISM

35. JOURNAL ARTICLES • “Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program” • “Stress in Medical Residency: Status Quo After a Decade of Reform?” • “Who is sicker: Patients – or Residents? Residents’ Distress and the Care of Patients” • “Heeding the Plea to Deal with Resident Stress” Annals of Internal Medicine March 5, 2002

36. 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.

37. ACADEMIC HEALTH CENTER “Moral tone frequently subverts rather than supports the development of good professional morals.” Huddle

38. 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

39. 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

40. “Today’s culture of medicine is hostile to altruism, compassion, integrity, fidelity, and self-effacement” Coulehan

41. REVITALIZATION

42. 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

43. THE GENERATIONS Baby VeteransBoomersCuspersBustersGen Nexters 1922-43 1944-59 1960-68 1969-79 1980-

44. “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

45. 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

46. REVITALIZING PROFESSIONALISM • Faculty development critical • System of evaluation • Professional tone and awareness set from the top! • Strong institutional support

47. REVITALIZING PROFESSIONALISM • Cognitive base • Experiential learning • Continuity • Role Modeling • Mentorship

48. “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

49. 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

50. 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