Some thoughts on professionalism

In the current online issue of the Journal, we present a series of, in our opinion, outstanding articles by van Mook WKNA and colleagues on professionalism in medicine [1], [2], [3], [4]. They present a state of the art review of the development of the concept and its current definition and in this capacity the series can be used as an introduction to the topic for physicians, students and other interested parties. In addition, they present an ambitious agenda for the teaching of professionalism to students and residents and review the current knowledge on assessment of professionalism.

As the authors point out medicine has a long history of addressing these issues. In the Western world physicians have long sworn allegiance to the Hippocratic Code or the Oath of Maimonides. These codes emphasize the primacy of patient welfare in the doctor–patient relationship. Other traditions and cultures have their own codes either written down or transmitted orally regarding the moral and ethical conduct of physicians. The authors posit that the intense interest in professionalism over the twenty years is a reflection of the way medicine is perceived by society. New definitions of professionalism have been developed that in addition to the traditional component of mandating ethical behavior emphasize the aspect of medicine as a public profession and the necessity to negotiate with society over values and preferences [5]. Altruism has remained a cardinal value of medicine, but the public now demands more from physicians. The rapid explosion of new technologies in medicine, the instant availability to patients of up to date information via the internet, changes in patterns of care and the increasing legalization of medicine all call for a new physician contract with society. In response to these changes, ethicists have also called for society to obligate itself in a series of commitments towards physicians and other healthcare workers. These developments are on the whole positive but it seems to us that what is missing is a sense of trust between the parties. A contract is an important document in a business transaction but a relationship needs to be built on trust. In order to regain this trust, physicians and their professional organizations need to be more pro-active in weeding out potential sources of conflict, making sure that all doctors are competent, lead the battle for providing care for the underprivileged and work to reduce the inequalities in the delivery of healthcare at the local and global level. Society needs to lessen the unrealistic expectations it sometimes places on physicians and develop a system that enhances patient safety without the constant threat of punitive or legal action against physicians.

In their review, van Mook WKNA and colleagues address the importance of the new professionalism on medical education. Like most authorities they advocate for formal teaching of the subject in medical school but point out the difficulties of doing so. There are almost limitless definitions of the concept and almost as many ways to assess and evaluate it. Notwithstanding all the laudatory efforts in creating curriculums in professionalism, we agree with their conclusions on the importance of the informal or hidden curriculum in teaching the subject. Hours of formal instruction in the classroom can be negated if appropriate behavior is not role-modeled on the wards and in the clinics. Notwithstanding the appropriate emphasis on professionalism in the curriculum there are disturbing data that students and medical students graduate with less moral sensitivity than when they started [6]. Is this due to behavior that is inappropriately role-modeled in the clinical environment? To help remedy this problem clinicians from all departments should be involved from day one in the teaching of professionalism. In addition, the selection of medical students should take into account the ability to attain excellence in professionalism as well as academic achievement. The white coat ceremony which many medical schools have adopted is useful in demonstrating the importance of adhering to a professional code and our medical school has developed a tradition of students writing their own ethical code which reflects their personal moral vision and professional responsibilities [7].

While much has been written on professionalism from physicians and ethicists in Western countries much less has been written from interested parties in the former Soviet Union and the developing world. In an increasingly global medical community, as recently demonstrated by the swine virus pandemic, it is imperative to understand to what extent these professional codes developed in the West are applicable to other cultures and societies. For example, as we have previously written unlimited human autonomy is not universally embraced as a supreme value [8]. These professional codes need to be broad enough to embrace the values of as many cultures as possible while not overlooking the tragic inequalities in medical care between the developed and developing world. There is an ancient Jewish tradition of trying to summarize the commandments of the Bible as tersely as possible. One of the suggested formulations is simply “Love your neighbor as yourself”. In trying to summarize all the multitude of components of professionalism we cannot help but hear the wise words of Francis Peabody “the secret of the care of the patient is in caring for the patient” [9].