Professionalism and the physician leader.

What is professionalism and how do professionals function? The identity of a professional is determined through the professional's occupational association with state licensing and regulatory agencies that hold the authority to set standards of practice, monitor and regulate individual practitioners, and control entry into the professional labor market.

Professional societies apply knowledge and expertise to the production of goods and services to meet the needs of every citizen. The economy should be capable of producing enough goods and services to give everyone in society equitable access to the full range of goods and services once available only to the rich and powerful.

Professionalism establishes standards, education and peer review that is structurally stabilizing and is a morally protective force in society. Professionals are obligated to respect human worth, be trustworthy, protect the values of society and remain competent in their chosen field. Most of all, professionals are to provide service for the common good! (1, 2, 3)

Physicians became a professional guild to be reckoned with beginning in the early 20th century after the famous Flexner Report of 1910 changed the education and training of the American physician workforce. (4)

With these changes, physicians sacrificed early earnings and personal wealth, studied their craft for an extended period of time and treated patients without regard for payment of services rendered in a respectful and professional manner.

In exchange for physicians accepting themselves as professionals, they received reasonable remuneration, reasonable work/life balance, autonomy, job security, deference and respect.

Physicians developed their own core elements of medical professionalism. (5)

1. The first element was a moral commitment to the ethical delivery of medical service, a devotion to medical service and its values.

2. The second element was that of a public profession open to scrutiny by the public. Physicians would be ethically and morally responsible to assert professional values in societal discussion on health care delivery.

3. The third element required physicians to engage in the political process of negotiation regarding health care delivery. Physicians were to advocate for health care values and balance those values against societal values in accordance with the times.

4. The fourth and final core element required physicians to possess and maintain a specialized body of knowledge and periodically demonstrate their professional acumen through certification examinations.

Physicians were also held to a professional social ideal. (4, 6) This ideal required a blending of social justice, equitable care for all and economic efficiency--managing limited resources in the face of societal unlimited wants and desires. By holding to this ideal, medical professionalism was noted a legitimate profession with autonomy and authority.

Certain legal privileges were extended to physicians that society would not allow others to possess. In return, physicians were expected to perform civically and provide social leadership in the public interest.

Decline of medical professionalism

The Flexner Report and subsequent studies resulted in shaping the focus of medical education and training in the past century.

* Physician training centered on the individual patient, not organizations or populations.

* Physician training empowered physicians to take personal responsibility for the health and well-being of their patients rather than delegate responsibility to others in the health care delivery arena.

* Physician training taught each physician to do their best for each individual patient rather than make trade-offs in a resource-constrained environment

This resulted in a steadily increasing workload for individual physicians and small group practices with subsequent high levels of workplace stress creating ill-prepared physicians to function well as members of large, complex organizations of managed care.

Physicians practicing today are currently facing: (4, 6, 7, 8)

* Greater individual accountability

* Patient-centered care

* Requests for more personalized service to patients

* Quality assurance and performance improvement initiatives collectively with their peers

* Evaluation by non-technical criteria and patient perception on their delivery of health care

* A growing culture of blame and finger-pointing

* High workplace stress

Physician unhappiness appears to be reaching an all-time high. (9) Even with record numbers of applicants to U.S. medical schools, experts project significant shortages and misdistribution of the physician workforce (i.e., primary care vs. specialization) in the next several years.

Physician unhappiness appears to center around the idea of doing more for less. Changes in expectations of the stakeholders in health care delivery and changes in medicine (e.g., reduction in physician autonomy, increases in physician accountability, emphasis on metrics and productivity) resulted in an increased workload for physicians with decreasing financial rewards.

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The decline of medical professionalism (3-8, 10) can be traced to several changes that occurred in health care delivery. There has been a heightened and increasingly expensive focus on complex specialization and scientific technology. The states, over time, have become involved in health care delivery in a lavish way by supporting medical research and growing medical institutions of higher learning such as medical schools and teaching hospitals.

Medical academia has supported federal initiatives of health care delivery including Medicare and Medicaid in order to provide education and training for future physicians. The American medical industrial complex has consistently geared itself for expansion whilst society and the state required some means of control over escalating costs.

The balance of power shifted away from physicians when a split between the elite of medical academia and the practitioners of the American Medical Association occurred during the above changes in health care delivery.

Reining in the powers of American medicine as part of a general social tendency to subordinate professional organizations more effectively to the control of the state and business is what ultimately led to the despair and desperation of modern day physicians.

Will physicians ever regain control over health care delivery or will the current model of managed health care delivery force physicians to accept a minimal role in patient care? Can physicians place their own financial motives second to the delivery of moral and ethical health care to their patients?

Restoring professionalism

Can physicians place their own financial motives second to the delivery of moral and ethical health care to their patients? The answer is a guarded yes. Physicians will have to answer this question individually and collectively as a profession.

There are five major areas that need to be addressed in order for physicians to regain control of the health care delivery system. (1, 4-6, 8, 10, 11)

* Patient trust

* Physician political power

* Population-based health care delivery

* National physician initiatives

* Physician leadership

In order to regain patient trust, physicians must begin performing charity work with underinsured and uninsured Americans. Physicians must begin reviewing, censoring, and praising peers. Physicians must also begin establishing leadership positions in community service. Subordinating financial rewards to professional norms with highly formalized scientific and technical knowledge grounded in social activism will lead to re-establishing a professional identity recognized by our society as a whole and by the individual patient.

The second area requires physicians to balance the current political power controlled by payers and employers in the delivery of health care. A call to political action must be on the minds of all American physicians, demonstrated at all levels of legislative action. Physicians should be allowed to regain their prominence as expert advisers at each level of government on issues related to health leading to legislative, regulatory and administrative decisions having a positive impact on health care delivery today.

Physicians also must embrace a population-based, patient-centered health care delivery system. Physicians need to learn and practice the principles of this delivery model. Understanding health enhancement, health risk assessment and demand, and disease and disability management will empower physicians to provide evidence-based medicine in a high-quality, cost-efficient manner that is customer-focused and service-oriented.

This leads to improved access to health care services as well as achieving outcomes such as increased patient satisfaction, decreased morbidity and mortality, cost efficiency and enhanced physiological and psychological function that will result in healthier lives for all Americans.

The fourth area requires physicians to embrace national initiatives to revive medical professionalism such as the Medical Professionalism Project and its charter on medical professionalism. (11)

Led by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation and the European Federation of Internal Medicine, the working premise of this project notes that changes in health care delivery systems in countries throughout the industrialized world threaten the values of professionalism.

A set of commitments or principles to the primacy of patient welfare, patient autonomy, and fair distribution of health care resources sets the stage for the heart of the charter. This project also defines a set of professional responsibilities geared to assisting physicians in achieving and maintaining the fundamental principles of the project.

The fifth and final area requires physicians to attain and maintain the skill sets necessary to establish results-oriented leadership for health care delivery. (12) Enhancing leadership practices through formal educational venues and mandatory continuing medical education, physicians will acquire and upgrade their technical expertise in managing cultures of organizations, change management, and bioethical considerations of health care delivery.

Leadership competency builds enduring greatness through a paradoxical combination of personal humility and professional will resulting in greater social accountability. This emotional intelligence, the ability to manage ourselves and our relationships effectively, consists of four fundamental capabilities:

* Self-awareness

* Self-management

* Social awareness

* Social skill

Leaders of all professions understand the importance of keeping current in their areas of expertise. Physician leaders are no different and an understanding that deriving power, both personal and professional, must occur by establishing strong interpersonal relationships with all the stakeholders of the current health care delivery system.

Acquiring core skills

The medical professional today more than ever is faced with both the clinical and administrative pressures of health care delivery. In order to better equip physicians with the skills necessary to deal with these new pressures, four main areas of expertise are required as core skills for today's medical professionals:

* Finance and health economics

* Medical informatics 

* Human resource management

* Human services management

Finance and health economics requires today's medical professionals to understand concepts in cost containment, resource utilization, revenue enhancement, operational budgeting and forecasting. Managing unlimited wants and limited health care resources is the basis for this core skill. Skills in innovation and reengineering will also enable medical professionals to become better equipped to handle the increasingly new demands of measured health care delivery today.

Medical informatics requires today's medical professional to understand concepts of computers and communication technologies to improve decision making in health care, patient care, and administration.

Medical informatics also demonstrates how to define, standardize, store, communicate, retrieve and analyze health care data for decision making, quality improvement and outcomes management.

Human resource management requires today's medical professional to celebrate the health care delivery workforce as agents for change in improving care. Delegating responsibility to mid and lower-level health care providers allows the medical professional to maintain intellectual capital and standards of medical practice.

Maintaining specialized knowledge and becoming responsible for its teaching elevates the medical professional in society and allows for traditional and newly acquired obligations to be met. Professional autonomy leads to self-regulation assuring quality care at all levels of the health care delivery system.

The fourth area, human services management, places the ultimate stakeholder of the health care delivery system, the patient, at the center of care. Acquiring and maintaining skills in population-based medicine resulting in high-quality care leads to acceptable outcomes embraced by all the stakeholders.

A reduction in medical errors and access to necessary clinical services by all patients' catapults today's medical professional back into a position of professional power accepted by society with reverence and pride.

It is with these skills and characteristics that physicians will regain control over health care delivery and level the playing field with all the stakeholders in the health care delivery system.

References

1. Cruess RL, Cruess SR, Johnston SE. "Professionalism: an idea to be sustained." The Lancet. 2000; 356: 156-159.

2. Krause EA: Death of the Guilds: Professions, States and the Advance of Capitalism, 1930 to the present. New Haven: University Press, 1996.

3. Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

4. Stevens RA. "Public roles for the medical profession in the United States: Beyond theories of decline and fall." Millbank Q. 2001; 79(3): 327-353.

5. Wynia MK, Latham SR, Kao AC and others. "Medical professionalism in society." N Engl J Med. 1999; 341: 1612-1616.

6. Gruen RL, Pearson SD, Brennan TA. "Physician-Citizens-Public Roles and Professional Obligations." JAMA. 2004; 291(1): 94-98.

7. Schlesinger, M. "A loss of faith: The sources of reduced political legitimacy for the American medical profession." Millbank Q. 2002; 80(2): 185-235.

8. Sullivan WM. "What is left of professionalism after managed care?" Hastings Cent Rep. 1999; 29:7-13.

9. Edwards N, Kornacki MJ, Silversin J. "Unhappy doctors: what are the causes and what can be done?" BMJ. 2002; 324:835-838.

10. Rothman DJ. "Medical professionalism--focusing on the real issues." N Engl J Med. 2000; 342: 1284-1286.

11. Medical Professionalism Project. "Medical professionalism in the new millennium; a physician charter." Ann Intern Med. 2002; 136:243-246.

12. Goleman D. "Leadership that gets results." Harvard Bus Rev. 2000; 78-90.

By Dale Block, MD, CPE 

Dale J. Block, MD, CPE, is a full-time practicing family physician, president of Block Medical Consulting, PC, and adjunct assistant professor in health management systems at Duquesne University in Pittsburgh, Pa. He can be reached at 412-221-1299 or [e-mail].

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