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Professionalism Reconsidered
Priorities for Physicians
Arch Fam Med. 1999;8:173-176.
FEW PHYSICIANS today believe that they are practicing in the "golden age" of medicine. Comprehensive social, technological, political, and economic changes challenge their adaptive resources. They also confront the forces of bureaucratization and corporatization1 that pressure them to subordinate their professional autonomy and control to other systems, and, in some cases, to place corporate benefit above professional values. Furthermore, many believe that the medical profession faces an internal crisis of moral standing and authority.1-3 Medicine's prestige has diminished, and despite potentially offering more to society than ever before in history, its role and conduct are openly criticized.1, 4-13 Some critics even question whether medicine has lost its status as a profession.
How should physicians respond? We have several options: (1) we can do nothing and let evolving social forces create our future; (2) we can react confrontationally and seek our own best interests much like a trade or a union; or (3) we can try to restore society's confidence by diligently, openly, and actively practicing professionalism. We can enlighten medical students and residents about what the term "profession" means. We can also inspire them with its potential for personal and public good by demonstrating its joys and obligations through our curricula and our professional role modeling.1, 14-15 Practicing physicians can also consciously affirm their calling into medicine and they can commit themselves once again to the values and obligations that ground their professional character, commitment, and craftsmanship.3, 14, 16
THE PHYSICIAN'S CALLING
The concept of vocational calling is familiar to those who enter religious communities. It is also pertinent to all who enter the profession of medicine. Loxterkamp17 eloquently reminds us that the physician's tradition is linked to "the parish priest, the rabbi, and the country minister" when he writes
we recognize this tradition in arms that hold, hands that stroke, shoulders that bear the brunt of responsibility when no one else steps forward. We know it as part of a life of service, something subsumed by that oddly antiquated word "vocation."
A calling is a mysterious occurrence. We can delineate its circumstances and we can feel its impact, but it is still intangible—like trying to clutch the wind, or gravity, or magnetism. We believe it because we see its effects, but it often defies logic and clear description. Humanly speaking, a professional calling is most akin to one's attraction to a life's mate, a decision that is never fully explained by a set of objective criteria. Rather, we experience such a calling as a powerful, incontestable attraction that draws us to discipline and commitment, even though it is hard to articulate exactly why. Calling to medicine as a profession rather than as a mere occupation involves that same type of conviction, irresistible attraction, and life-changing commitment.
THE PHYSICIAN'S CHARACTER
The physician's role embodies many essential character values and attributes. Some are not "natural" in the sense that they are innate. Physicians will also differ in the degree to which they manifest these values and attributes, because their personalities and gifts differ. All can be learned, however, and perfected through modeling, self-discipline, and habitual application, and they all form the composite of the compleat physician's character.
An Understanding of History
Martí-Ibáñez18 reminds us that
. . . the physician's daily work is wrapped up in the subtle web of history. [Our] labors are linked with those of [our] colleagues who preceded [us] in history and those who are now working all over the world. It is this spiritual unity . . . that has made medicine so universal and so eternal.
Understanding history also provides the wisdom, context, and perspective with which to construct our futures.
An Appreciation for Literature and the Arts
Literature and the arts contain the world of values and record the wisdom of our culture's best minds. Coles19 reminds us that through this world we can experience the lives and struggles of professionals like ourselves who face ethical dilemmas and who are tempted to compromise their calling through rationalization, poor judgment, greed, and desire for power, status, and prestige. Literature also provides an opportunity for self-analysis. By vicariously living the life of another we can scrutinize our own values, decisions, expectations, beliefs, hopes, and assumptions.
Honesty and Personal Integrity
Honest physicians are genuine, reliable, and truthful, with motives that are pure, open, and free from prejudice or malice. Integrity implies that their personalities are unimpaired and incorruptible. Furthermore, it commits them to live a principled life—to act consistently with the personal values and convictions that they publicly espouse. Confidentiality, trust, honor, duty, responsibility, and dignity rest on these virtues.
The Grace of Humility
The attitude, "There but for the grace of God go I," is "one of the finest flowers of the human spirit" and the "solvent of intolerance and selfishness and the other deadly sins."20 In this context, grace embodies the quality of mercy or pardon, and humility eschews arrogance.
Simplicity
Simplicity liberates. By decreasing complexity it makes life more manageable. It also frees us to focus on the essence of things rather than on less important details. Furthermore, it is one measure of greatness. A person's enduring greatness is not measured by amassed wealth, or power, or the extravagance of one's lifestyle. It is authenticated, rather, by the quality of one's character, the socially redeeming value of their work, and the simple grace and humility with which they live their lives.
Faith in Life's Meaning and Value
Whereas physicians cannot always cure, faith in life's meaning and value encourages them to always give hope. To give hope is to give life in a world where, according to Thoreau, "the mass of men lead lives of quiet desperation." Faith in life's meaning and value also leads us to respect all people and to honor their personal dignity.
Compassion
True compassion is that deeply seated human response that motivates us to reach out to others in distress without thought to our own circumstances. Compassion values the personhood of others and demonstrates itself through action that commits one to fellowship, sharing, support, and companionship with those who suffer. The physician's moral credibility springs from compassion.21
The Virtue of Work
Aristotle taught that we find happiness through mental and physical activity when we do things that we take pride in doing well. Enjoyment, therefore, is not merely amusement, entertainment, or relaxation. It is satisfaction that emanates from what we do with our life's work rather than what we do apart from that work. Work also predicts accomplishment. Osler22 credited his success to this "master word in medicine" that could "make the stupid man bright and the bright man brilliant."
Method and Thoroughness
These attributes enable physicians to practice their craft with precision as they sift through masses of undifferentiated data, sorting and ordering that data to resolve their patients' problems. When the orderly, rational world of science intersects with the disorderly world of disease, method and thoroughness help to separate truth from error and to discern those practices and ideas that arise from tradition, superstition, ignorance, and blindly followed ritual.
Willing Submission to an Ethical Code
The tenets of medicine's code of ethics are far more stringent than legal controls. Submission commits one to patient advocacy, a tradition of duty, the primacy of the patient, social responsibility, the obligation to maintain internal discipline, respect for life, and the hippocratic axiom never to intentionally harm or injure anyone.
THE PHYSICIAN'S COMMITMENT
Beyond calling and character, the profession of medicine demands a commitment to service and to medicine's tradition of duty—commitments that take precedence over any economic interest. All definitions of medical professionalism embrace this core principle.23-32
A Commitment to Service
Racy33 reminds us that
both society and the professional understand that the rewards follow the service and are secondary to it. Professionals do a good job under all conditions, not only when well rewarded. They do so because a good job is expected of them and defines them.
Pound34 also emphasized the importance of service when he commented that a professional's work is
a public service—nonetheless a public service because it may incidentally be a means of livelihood. . . . An organized profession does not seek to advance the money-making feature of professional activity. It seeks rather to make as effective as possible its primary character of public service.
The principle of autonomy is essential to the nature of professionalism. Freidson32 has studied professionalism extensively and concludes that one of its "most strategic distinctions lies in legitimate, organized autonomy—a profession is distinct from other occupations in that it has been given the right to control its own work." Just as society grants autonomy, however, society may withdraw it. Friedson32 warns that
if a profession's work comes to have little relationship to the knowledge and values of society, it may have difficulty surviving. The profession's privileged position is given by, not seized from, society, and it may be allowed to lapse or may even be taken away.
A Commitment to Duty
The profession's tradition of duty extends to teachers, to society, to patients, and to colleagues.
As "parents of our minds," next to our familial parents, teachers are perhaps the most important people in our lives. We should honor them with devotion and with friendship.
Society expects us to seek knowledge that will benefit all its members; as clinicians, it needs us to cure and to care; as teachers, it requires us to disseminate our knowledge and skill.
Our duty to patients is to become partners with them in health care, and to skillfully use all our "physician" virtues as we care for them and advocate on their behalf. We are also obligated to pursue our specialized knowledge and skill so that we can serve them with lifelong competency.
Our duty to our medical colleagues requires both support and discipline. All physicians share a common heritage, and a common task. The community, collegiality, and commonality that all once shared, however, is now threatened as increasing specialization diminishes a shared value system and weakens relationships in favor of self-interest and competition.15, 35 Physicians need to become supportive colleagues once again and to diminish the internal competition and rancor that only further fragment the profession's identity and privilege.
The need for collegiality and community, however, does not mean that we can tolerate professional irresponsibility, incompetence, or unethical behavior. On the contrary, peer review should become even more exacting. Reed and Evans31 argue that rigorous peer review "may be the most crucial factor in whether or not physicians maintain control over the standards of their profession," and it "must be independent and have the power and predisposition to enforce the profession's standards."
As physicians we must impose discipline on ourselves. If we fail, we will be forced to accept it from others, and with that acceptance lose the ability to control our own work. When that happens we will have lost our professional privilege and autonomy.
Friedson36-37 also calls for a new sense of professional candor. We should routinely open our practices and decisions for inspection and evaluation. Furthermore, trade secrets and property rights have no place in a professionalism that obligates us to provide our colleagues with all the data on which we base a decision or conclusion, and to publicly share results that can improve personal and community health.
THE PHYSICIAN'S CRAFTSMANSHIP
Superior craftsmanship defines the medical profession. To become an excellent doctor, one cannot possess mediocre skills. Professionalism demands a commitment to excellence.
Maintaining excellence in medicine is not easy. Medicine inherently demands more than many occupations because it is simultaneously an experimental science, an applied science, and a practical art. The physician's activities are primarily intellectual, grounded in science and learning. In distinction to the scientific and scholarly disciplines that create the knowledge on which modern medicine rests, however, medicine is a practicing profession. It carries the burden to bring science and scholarship to the level of everyman in everyday life and to translate it into everyman's understanding.
PRACTICING PROFESSIONALISM
Talking about professionalism is not enough. We need to act on our convictions. Whereas there is no universal protocol to guarantee success, there are many things we can do to demonstrate professionalism. A conscious choice to behave differently in only one seemingly small area will facilitate our ability to adopt other behaviors as well. This is good reinforcement psychology that is also supported by good metaphor—the fork in the road that, once taken, "makes all the difference," or the single spark that ignites a conflagration.
Evaluate Your Professional Calling
Examine yourself by seeking honest answers to some serious questions. Self-analysis is not easy, and it is not a perfunctory task. Facing yourself honestly takes courage. Ask yourself, Why was I attracted to the profession of medicine? Have those original attractions and convictions changed? Am I still satisfied with my life as a physician? Where are my primary commitments? To what or to whom am I most dedicated?
Am I still practicing with skill and competence?
Work to Develop Your Professional Character
This process is uniquely personal. Pick 1 or more of the following suggestions and give it your concerted effort.
- Read the literature that portrays the moral and ethical struggles that physicians face and that depicts the quality of their lives, their joys, and their sorrows. Live vicariously through these characters and learn from their experience.
- Read medical history. Identify with the lives of famous physicians and apply the lessons and perspectives of history to create your own future.
- Struggle with the ethical dilemmas that confront physicians daily. Through reading and dialogue, ponder these issues with colleagues. Then articulate and record your own reasoned positions.
- Write a personal code of ethics, listing the principles by which you live your life and conduct your practice. Keep it before you so that you can hold yourself accountable. Share it with others so that they can also hold you accountable.
- Before criticizing a colleague who has failed, gather information that will illuminate the context and the nature of the problem. Then help with restitution.
- Consciously think about doing good and serving others more than about making money.
- Embrace work as a positive value rather than as something to avoid or to minimize.
- Base your clinical practice on evidence from modern biomedical, psychosocial, and epidemiological science.
- Learn principles of critical thinking and formal decision making and apply them to your practice.
- Read, understand, and practice a professional code of ethics (eg, the American Medical Association Principles of Medical Ethics).
Publicly Display Your Commitment to Service and Duty
One may begin meeting this professional goal through activities such as the following:
- Express personal appreciation to teachers who have shaped your life.
- Participate in clinical research to create new knowledge, to integrate known knowledge, and to apply knowledge through evidence-based guidelines and outcome studies.
- Volunteer to train and socialize the next generation of physicians by teaching medical students and residents.
- Treat your patients in the manner with which you wish to be treated when you are a patient.
- Lay aside specialty turf battles and focus on individual competence as the measure for evaluating and credentialing clinical privileges.
- Publicly praise, rather than denigrate, professional colleagues from other specialty disciplines.
- Collaborate to design integrated health care teams that will coordinate optimal roles and responsibilities for primary physicians and other specialists.
- Work with colleagues to define professional standards of conduct for physicians.
- Freely submit your clinical practice to peer evaluation and actively participate as a peer reviewer for colleagues.
- Openly share new information that can improve diagnosis and management with all professional colleagues.
Continuously Maintain and Improve Your Professional Craftsmanship
This may be demonstrated through activities such as the following:
- Participate in personal quality improvement programs designed to evaluate and to improve your clinical performance.
- Learn new skills that will improve your ability to serve your patients.
- Voluntarily quit performing procedures that no longer meet quality standards.
- Courageously leave medicine and direct your life's work toward other professional or nonprofessional careers if you have lost your professional calling, cannot regain it, entered medicine for reasons other than a profound attraction to its professional values and obligations, or cannot submit to the rigorous process of continuous renewal.
FINAL THOUGHTS
Since much of this discussion has centered on the physician's clinical practice role, some may assume that it is less relevant for those physicians who primarily teach, conduct research, or promote health through political or administrative channels. On the contrary, these professional attributes and obligations apply to all physicians, regardless of their vocational focus. All contribute to the profession and all are committed to society's health and welfare. All must experience a calling to their profession, display essential character virtues, demonstrate commitment, and apply their craft with utmost skill.
As a profession we have made mistakes, we face increasing skepticism as an organized body, and we have lost a measure of trust and prestige. We confront those who would barter our craft as they would any other commodity, and those who view us only as competitive providers in a service industry. As professionals, however, we can face these difficult times with honor and dignity by affirming and demonstrating the virtues, values, attitudes, and behaviors that serve the interests of patients and society above our own, that recall for us medicine's tradition of duty, and that challenge us to learn and to apply our craft with excellence and dedication.
AUTHOR INFORMATION
Accepted for publication September 24, 1998.
Corresponding author: John G. Halvorsen, MD, MS, University of Illinois College of Medicine at Peoria, 815 Main St, Suite B, Peoria, IL 61602 (e-mail: jgh{at}uic.edu).
John G. Halvorsen, MD, MS
From the Department of Family and Community Medicine, University of Illinois College of Medicine at Peoria.
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