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How Professionalism in Medicine is Changing
New York, NY
Remarks based on a talk given to the Coalition for Physician Responsibility
My favorite definition of professionalism is that provided by Justice Louis Brandeis over 100 years ago and modified by one of my mentors, Samuel Thier. He defined the learned professions as having three characteristics:
- A learned profession is in possession of a specialized set of knowledge and skills that it is responsible for mastering, for improving, and for passing on to the next generation. This characteristic speaks to attributes of competency, continuous self-improvement and generativeness.
- A learned profession puts others’ needs ahead of its own. This characteristic speaks to altruism and stewardship.
- A learned profession is self-regulating. This is a privilege conferred by society in exchange for being faithful to the first two characteristics.
We have a mixed track record in medicine with regard to these characteristics.
First, while individual competence remains high among our physician workforce, our collective competence to meet all societal needs is lagging. And yes, our medical educational programs have been models for the world, and we have a pipeline of well-qualified students and trainees to carry on the work of the profession. But we are working in an increasingly collaborative practice world and we physicians have not always been willing partners in interprofessional activity in our schools and clinics and the shared professional responsibility we have to educate the next generation of health professionals.
Second, in spite of many, many examples that we all know of truly altruistic physicians, there is a public perception – supported at least in part by data – that we do not collectively, consistently act altruistically. This perception is based on reported very high incomes for some physicians in a fee-for-service system, demonstrated great regional variations in the use of procedures and in patient charges, and sometimes-questionable relationships between physicians and pharmaceutical and device companies. Our altruism is also questioned because of barriers to access to care for many, and all too frequent experiences with care that is inattentive or poorly responsive to needs.
Third, while physicians have always valued autonomy, they have not necessarily valued self-regulation – in fact, they have sometimes seen it as an impingement on autonomy. There is a lot of talk (and lamenting) of physician loss of autonomy today. But physicians, of course, have never been totally autonomous. Even my father – a general practitioner with his office in our house – was not totally autonomous. He was licensed by the state, he cared for patients in local hospitals and nursing homes with in which he had to be privileged, and perhaps most importantly, he saw his patients every day in the town he lived in with them and received regular personal feedback.
Self-regulation is not purely self as there are other stakeholders that legitimately believe they have some say. These include at the very least those paying for care (government and private payers) and those receiving care (patients and communities). This is being acknowledged today by an increasing trend of public members on the boards and committees of regulatory bodies, care delivery organizations and health professional education institutions. I think this trend is to be encouraged because it acknowledges the important interrelationship with the society we serve.
I believe that the landscape of professionalism will continue to evolve – not because the meaning of professionalism has changed but because the best way to express and achieve professionalism will require new models and mechanisms.
Currently two important changes are occurring that I believe have an impact on how professionalism will be expressed and interpreted today and in the future. These are (1) the increasing importance of teamwork and interprofessional collaboration and (2) the increasing importance of organizations that employ physicians and provide the environment in which professional activity takes place. Both of these trends could have positive or negative effects on professionalism and may require us to consider new factors in how professionalism is supported and expressed.
Learn more about a Macy-funded professionalism initiative with the Institute on Medicine as a Profession (IMAP).