Professionalism, where are you?

Abstract

The practice of medicine continues to evolve in ways that are not always compatible with good patient care, and physicians now control less and less of their practices. One of the casualties of the new health economics is the concept of professionalism, which becomes more difficult to adhere to in the face of restrictions placed by outside forces. Nevertheless, physicians can maintain a sense of professionalism despite all the difficulties. Indeed, we must do so in order to remain true to our ideals.

Introduction

Recently I was asked to evaluate a brain-injured patient for a tracheostomy. The patient was an elderly woman who had sustained an injury from a fall. In reviewing her chart, I noticed that the neurology consultant had mentioned in his history, in bold letters and underlined, that the managed care organization's family physician had not ordered a brain scan during the patient's initial presentation to the emergency room 6 hours earlier. Now the patient had been brought back to the emergency room, unconscious and with a large subdural hematoma. I showed the neurology consultant's report to another physician. He lamented that physicians are no longer as collegial with each other as we once were and that there is less professionalism than there used to be in our practice of medicine.

The recollection of this incident leads me to ask, Are we losing our professionalism? And if so, how can we reverse the tide and restore it?

Attributes of a profession

The term profession originates from the Latin profiteri, which means to declare aloud, to make a public avowal. The term entered the English language in the 13th century as a means to signify that a person had made a solemn public vow to enter into religious service, such as a nun would do. In the 16th century, the meaning of the word was broadened to include the making of a public declaration that a person had entered into an occupation that saves life or soul, and it usually referred to the work of priests, physicians, and lawyers. [1] The meaning of the term was expanded again during the early part of the Industrial Revolution in the 19th century to describe any worthwhile vocation in which a person made money. In the beginning of the 20th century, the term became part of the lexicon of the world of sports, as professional athletes were distinguished from amateurs by the simple fact that they openly received money for their athletic performance. Thus we have teen-aged basketball players metamorphosed into professionals without any college education.

There are numerous definitions of a true profession, [2] but they have five characteristics in common:

Specialized knowledge. A professional is in possession of a specialized body of knowledge that is valuable to society.

Exclusivity. Entrance into a profession requires its members to have academic degrees, certification of competency, and a license.

High ethical standards. The ethical standards of a profession are high, and

its members are expected to abide by its code of conduct.

Autonomy. By virtue of their specialized knowledge, professionals are permitted to exercise their own judgment in the delivery of their services.

Accountability. Even though professionals are autonomous, they are nonetheless accountable to regulatory agencies and their peers.

The medical profession has several characteristics that set it apart from some other professions. According to Sir William Osler, "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head." [3] Osler noted in 1932 that the medical profession had four other laudable features: 1) its noble beginnings in the skeptical and critical Hippocratic school, 2) its remarkable solidarity, 3) its progressive nature, and 4) its existence for the benefit of others.

In 1994, P.P. Reynolds, MD, a Robert Wood Johnson Foundation Scholar at the University of Pennsylvania, wrote that the medical profession has a set of values, attitudes, and behaviors in the service of others that is unique. Two values that are essential to the practice of medicine are honesty and integrity. Other desirable attributes are humility and an accountability to patients, colleagues, and society. A physician should be nonjudgmental and respectful of patients. He or she should pursue knowledge and the improvement of skills with a lifelong commitment to competency and with a collegial and cooperative approach to other members of the healthcare team. Finally, the physician should devote time to community service and public leadership to fulfill the goals set forth for the profession by the public. [4]

The "deprofessionalization" of medicine

Medicine is not the only calling that has struggled to hold on to its professionalism. For example, the legal business retains the outward appearances of a profession, with its lofty goals of truth and justice, but its energies are often sold to further the goals of the untruthful and the unjust. Medicine has been able to retain its professional status to a greater extent than has the legal community, but our professionalism is still threatened by a confluence of new and old forces: technology, corporatization, specialization, failure, and greed.

Technology. Technology in medicine is a two-edged sword. On the one hand, the improvements in care brought about by advanced technology confer on physicians the respect and praise of the public. On the other hand, technology reduces the physician's role to that of a mere purveyor of healthcare services. The physician is to healthcare what a pilot is to air travel--important but generic. When people wish to fly from point A to point B, they do so regardless of who the pilot is. Likewise, when they are sick, they want to get well regardless of who the physician is. Once the understanding of biotechnology becomes widespread, the healing process becomes more understandable to the public. As the healing process loses its mystique, the physician becomes perceived as more of a technician than a professional. In the end, technology can depersonalize and "de-professionalize" a physician. [5]

Corporatization of medicine. In 1980, Arnold Relman, MD, then editor of The New England Journal of Medicine, described a phenomenon that he called "the new medical-industrial complex." [6] In 1982, Paul Starr, writing in The Social Transformation of American Medicine, traced the gradual takeover of the practice of medicine by large corporations. [7] Both men warned about the ethical dilemmas that physicians would face while practicing under these conditions.

For-profit corporations emphasize the bottom line because they owe their allegiance to their stockholders. There are many ways to make a profit; one way, although certainly not the best way, is to simply charge more and deliver less. Because physicians are responsible for ordering up to 80% of all healthcare services, it is obvious that in order for a healthcare corporation to deliver less, it must control the physician. [8] The most benign method of controlling physicians is to put them on salary so that their income is not influenced by or dependent on the number of tests or procedures they order. The most malignant way to control physicians is to inversely associate their income with the level of services they order. A capitated physician in U.S. Healthcare, the HMO of the Aetna insurance company, has as much as 50% of his gross income at risk. [9] One component of his income is a bonus, which rewards the physician for meeting clinical and marketing goals and achieving a high level of patient satisfaction . Another component is punishment in the form of withheld income for ordering an "excessive" amount of clinical services.

Because an individual physician's patient base is not large enough to spread his risk, physicians can also find themselves reluctantly practicing bedside rationing. Two physicians in California were found liable for malpractice because they failed to refer a cancer patient to a specialist in a timely manner. [10] The patient's attorney argued that such a referral would have cost the physicians more than $1,000 because the patient was insured under a capitation program. The patient subsequently died, and the judgment against the physicians for negligence was in excess of $3 million. The corporatization of medicine shifts the risk of medical care to the physician and creates a conflict of interest. Ultimately it can lead patients to distrust us. [11,12]

Another unexpected outcome of corporate medicine is the proliferation of medical directors. One of the stated purposes of their employment is to improve the quality of healthcare by making sure that medical resources are used appropriately. However, medical directors are invariably asked to make decisions that involve the denial of healthcare services. A review of the literature shows that physician-operated independent practice associations are more miserly than commercial HMOs when it comes to the amount of medical service they deliver. [13-16] The inference of these articles is that many medical directors have compromised themselves. A medical director in California was found liable for denying care to a member of his health plan; the judgment against him was more than $1 million. [17] In Arizona, several medical directors were censured because the state medical board there considered their decision to deny care to be unprofessional conduct. [18] When these court cases are sensationalized by the news medi a, it diminishes the public's trust in physicians in particular and the healthcare system in general.

Specialization. Many physicians specialize so that they can truly be proficient in their area of interest. [19] Unfortunately, there are several negative aspects to specialization. Quite often the specialist has no personal relationship with or knowledge of a patient prior to their first encounter, so it is not uncommon for specialists to identify patients by their disease rather than as human beings who happen to have a disease. A patient who has multiple-system problems is often shuttled from specialist to specialist without any coordination or continuity of care. Norman Cousins, the Cultural Ambassador to the Soviet Union during the Nixon administration, recounted his humiliating experience during his hospitalization in the VIP suite at the UCLA Medical Center. [20] He complained about the uncoordinated, impersonal care that he received at the hands of the super-specialists and their residents.

In the fee-for-service setting, specialists had more power, prestige, and money than did primary care physicians. Under managed care and the gatekeeper system, the power, if not the prestige and money, has shifted. The attitudes of specialists and generalists toward one another has become less collegial. For economic and political reasons, many specialists join only their specialty organization and ignore the umbrella organization, the American Medical Association. The prestige and the political power that the medical profession enjoyed during the early part of the 20th century were derived from physician unity and a high standard of practice based on scientific knowledge. This unity is now weakened. Each specialty makes its own policy, and frequently these policies are contradictory, which lessens the profession's credibility and the public's trust.

Spectacular failures. In the early stages of scientific medicine, a number of new discoveries, such as vaccines and antibiotics, led to the elimination of some common serious diseases. The presumption was that as time went by, all diseases would eventually be conquered. However, physicians continue to encounter intractable diseases-- such as chronic heart diseases, stroke, cancer, AIDS, and some neurologic disorders-and the initial optimism that we would quickly conquer all diseases has faded. Moreover, some infectious diseases that we thought we had conquered have returned to haunt us, thanks to antibiotic-resistant bacteria.[21,22]

We now realize that the eradication of some diseases is not imminent, and we can provide only palliative care. This has proven that physicians are not omnipotent after all, and that there is a limit to what medical science can do.

Greed. "The love of money is the root of all evil.'[23] One hundred years ago, the medical profession was among the lowest paid in the United States.24 But after the introduction of Abraham Flexner's medical education reforms, entry into the medical profession became more restricted, and the profession became more exclusive. Eventually, physicians monopolized the practice of medicine.[25] With the introduction of healthcare insurance in the 1930s and the massive infusion of federal and state money into the healthcare system since 1965, the physician has become one of the highest-paid professionals in this country.[26] Because a third party has become responsible for most of the payment of healthcare services, it did not take long for unscrupulous physicians to realize that insurance companies are cash cows waiting to be milked.[27] In 1991, Buchanan et al estimated that between 10 and 25% of all Medicare and Medicaid billings were fraudulent and that the cost to these programs was as high as $66 billion.[28] Jesilow et al, in analyzing the cases of 147 felons convicted of Medicaid fraud, revealed some of the more egregious billing practices[29]:

* One psychiatrist billed for 4,800 hours of consultations in a single year. This would have required him to have worked more than 15 hours a day, 6 days a week.

* In 48 instances, an obstetrician billed for two abortions a month for the same women, some of whom had already had a hysterectomy.

* An ophthalmologist billed Medicaid for $1 million during a 5-year period. The matter came to the attention of the Medicaid program because many of his patients had lost their sight. The ophthalmologist was sentenced to 4 years in prison.

And the fraud continued. A urologist in California kept a patient addicted to narcotics for 15 years.[30] During that time, he prescribed narcotics in return for auto service. He was found liable for malpractice, and a jury awarded the plaintiff $900,000.

The amazing thing about these felons is that they generally perceived themselves to be sacrificial lambs who had been led to the altar by their incompetent or back-stabbing employees or as victims of inane laws and bureaucratic nonsense. None of them seemed to have a twinge of compunction or any insight into the fact that greed was the source of their transgressions. It is the patient's right to expect physicians, in whom they have placed so much trust, to be ethical, honest, and competent. When patients are bombarded with accounts of gross negligence, incompetence, greed, and fraud, they can lose trust in their physicians.

Restoration of professionalism

The practice of professionalism does not always come naturally. Many medical educators believe that professionalism must be taught.[31] The problem is that it is not taught often enough in medical schools and during residency training. In his close observation of the interaction between teachers, residents, and patients, David Stern, MD, PhD, of the Ann Arbor (Mich.) VA Medical Center, found that cherished values such as honesty, accountability, and caring are barely discernible during teaching rounds and that equally important values such as altruism, nonmaleficence, and confidentiality are conspicuously absent.[32] Moreover, physicians in private practice are no longer being nurtured in an academic environment where medical ethics are respected and taught.

Recognizing these deficiencies, in 1994 the American Board of Internal Medicine (ABIM) developed Project Professionalism. According to the ABIM, "Project Professionalism is dedicated to promoting integrity within the specialty of internal medicine and its educational environment and among all internists and subspecialists. Its principles are committed to the enhancement of professionalism by the medical profession as a whole."

Professionalism is taught to both residents and practicing physicians through the use of hypothetical ethical situations and guidelines for dealing with them. Project Professionalism reinforces the fact that behaviors relating to abuse of power, arrogance, greed, misrepresentation, impairment, conflict of interest, and a lack of conscientiousness are unprofessional. At the same time, it reminds us that in order to promote professionalism, we need a strong sense of altruism, accountability, excellence, duty, honor, integrity, and respect for others. It would be beneficial for all physicians to adhere to the principles espoused in Project Professionalism. (For a copy of relevant information, contact Linda L. Blank, Vice-President for Clinical Competence and Communication, ABIM, 510 Walnut St., Ste. 1700, Philadelphia, PA 19106-3699. Phone: [215] 446-3562; fax: [215] 446-3474.)

Unfortunately, physicians cannot practice pure altruism in the current medical environment. But although our knowledge and skill are for sale, our professionalism and ethics are not. We will never need to prostitute our profession. It is our duty to honor, protect, preserve, and promote professionalism.

Acknowledgment

The author expresses deep appreciation to Professor Kenneth Czisney, PhD, of California Lutheran University, for his wisdom and guidance in shaping my philosophy on bioethics.

From the Ventura County (Calif.) Medical Society.

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