Professionalism in Medicine by wuyunyi


									Human Resources for Health

                                    Professionalism in Medicine
                                                     K R Sethuraman*

   “...nothing is more estimable than a physician who, having studied nature from his youth, knows the
   properties of the human body, the diseases which assail it, the remedies which will benefit it,
   exercises his art with caution, and pays equal attention to the rich and the poor.” − Voltaire

Introduction − What is Professionalism?                             Profession and Vocation
Professionalism has been described by the                           To differentiate between a vocation and a
American Board of Internal Medicine as                              profession, recent sociological literature has
“constituting those attitudes and behaviors that                    proposed a ‘checklist’ method. An
serve to maintain patient interest above                            occupation is considered to be a profession
physician self-interest.”1 The word profession is                   if:
derived from profess which means 'to proclaim
something publicly'. The act of 'profession' of                            •     Practising it           requires       formal
commitment to an ideal to which the                                              education;
professional should conform is the essence of                              •     Its members enjoy control over their
a profession. Physicians profess two things: to                                  own training standards;
be competent to help the patients and to have                              •     Its members have their                    own
the patient’s best interests in mind. Such                                       disciplinary mechanisms;
commitment invites trust from their patients.
                                                                           •     There is a scholarly journal devoted
     Physicians profess in two ways: the first is                                to its standards;
the public act of 'oath taking' during medical
                                                                           •     Its practitioners enjoy relatively high
graduation ceremonies. This is truly the
                                                                                 social status, and
moment of transition – from being a student to
becoming a professional. The oath, not the                                 •     Its practitioners have secured
medical degree, professes the way the newly-                                     protection from state regulation as
acquired competencies are to be employed.                                        well as from market pressures.
Without the oath, the doctor is just a skilled
                                                                           The checklist method permits us to
worker. The second way of professing is
                                                                    debate whether or not certain occupations,
implicit in the doctor-patient encounters:
                                                                    like librarian, social work and journalism are
Whenever a physician asks the patient, “What
                                                                    professions. Traditionally, a small number of
can I do for you?” they commit themselves to
having adequate technical expertise and to                          professions, by virtue of their educational
using that in the best interests of the patients.                   breadth and their importance in satisfying
Such tacit commitment occurs every day                              some fundamental human need, have been
between a physician and a patient. Otherwise,                       called “learned professions.” Medicine, law,
the patient would never willingly consult the                       ministry and other academic occupations
physician.2                                                         have enjoyed this special status. 3

* Director-Professor of Medicine and Head, Departments of Medicine and Medical Education, JIPMER, Pondicherry 605006. India;

Regional Health Forum – Volume 10, Number 1, 2006                                                                              1
History of Professionalism                           persuading the patient to comply with the
                                                     therapy. ”
   "Three kinds of medical practitioners are               In the early 20th century, professionalism
  found in this world; firstly, the impostor in      included issues like maintaining technical
 physician's robes; secondly, the vainglorious       expertise and self-regulation of medical
 pretenders and thirdly, those endowed with          practice. Formulated by Talcott Parsons in the
        the true virtue of the healer" −             1920s, these tenets formed the foundation of
           Charaka (120−162 AD)                      professionalism. In the developed world,
                                                     technical expertise improved with the Flexner's
The noteworthy physicians in the history of
                                                     report of 1910 on Medical Education but
medicine − physicians of the ancient Hindu,
                                                     quality of education is still a matter of
Confucian, or Hippocratic schools, Thomas
                                                     concern in developing countries. Self-
Percival, Francis Peabody and William Osler,
                                                     regulation by the profession has always been
etc.- practised virtue-based ethics. However,
                                                     its Achilles’ heel: Most professional bodies do
for several centuries 'the mercenary doctor'
                                                     not effectively discipline their members; most
has been a problem. "A doctor who can help
                                                     do not publish records of their disciplinary
a poor man and will not do so without a fee,
                                                     actions, if any. Such shortcomings make it
has less sense of humanity than a poor
                                                     clear that effective self-regulation is non-
ruffian who robs a rich man to supply his
                                                     existent and needs to be created.5
necessities. It is something monstrous to
consider a man of liberal education tearing               The de-mystification of the medical
the bowels of a poor family by taking for a          profession in the 1970s and 1980s resulted
visit – as fee – what would keep them for a          in two great upheavals. First, medicine
week,"       lamented      Richard      Steele       changed from an autonomous, publicly
(1672−1729). In Sanskrit, there is an ancient        respected profession to one vilified in the
couplet, which says, "A physician is the elder       public press. Doctors, once the ‘perfect
brother of Yama, the Lord of Death, because          angels,' had fallen from the pedestal of
Yama takes away only your life but the               public adulation. Second, health managers
physician takes away your life and all your          appeared to be potent rivals for the authority
money!" 4                                            that physicians thought they owned.
                                                     Sociologist Paul Starr commenting on the
      Plato had described two types of doctor-       growing privatization and monetarization of
patient relationships. The first – 'slave            medicine, described medicine as a
medicine' in his parlance – is described thus:       “sovereign profession”, that once had
“The physician never listens from the slave          reigned supreme, but was now threatened
any account of his complaints, nor asks for          by the “coming of the corporation.”5
any; he gives some empiric treatment with an
air of knowledge in the brusque fashion of a               Today, medical professionalism is in
dictator, and then is off in haste to the next       peril as several factors have weakened it.
ailing slave.” Plato contrasted this with the        Increasingly, physicians encounter perverse
                                                     financial incentives as well as restrictions,
physician-patient relationship for 'free citizens'
                                                     fierce market competition, and the resultant
thus: “The physician treats their disease in a
                                                     erosion of patients’ trust. Professionalism has
scientific way and takes the patient and his
                                                     virtually vanished in the battle between
family into confidence. He never gives
                                                     market competition of the "health care
prescriptions until he has won the patient’s
                                                     industry"    and     ineffective    government
trust, and when he has done so, he aims to
                                                     regulation of health care services.5
produce complete restoration to health by

2                                                    Regional Health Forum – Volume 10, Number 1, 2006
Perspectives of Professionalism                          •    Compassion – empathize and feel
                                                              something of the patient’s plight in
Professionalism in medicine can be viewed                     order to make scientific judgements
from the perspective of professional virtues or               that are morally defensible and
that of professional obligations. Professional                suited to the life-world of a
virtues are the desirable qualities and traits a              particular patient, and
physician ought to possess and professional
                                                         •    Truthfulness – enables the patient
obligations are what a responsible physician
                                                              to make informed choices, on
needs to understand and do.
                                                              treatment modalities.
                                                         These are virtues obligated by the
Professional Virtues                                dyadic nature of the medical encounter
                                                    between a physician and an individual
"Virtue engenders excellence; therefore virtue      patient.2
    ought to be fostered more than life." −
        Tiruvalluvar − Tamil Saint-Poet
                                                    Professional Obligations
Medicine has always been considered a
"noble profession." The image of a doctor has       Professions have a duty to protect vulnerable
always suggested integrity, loyalty and             persons and vulnerable social values. Many
compassion – key aspects of a physician’s           values are vulnerable: individuals and
professional identity. The world over,              societies may abandon the sick and the
communities have always acknowledged                elderly, and permit unequal treatment based
medicine's vital role in healing the sick and       on gender, etc. Though humanism,
permitted unique powers and privileges to           trustworthiness and the preservation of
those who practiced it. In turn, the societies      important values are important for all
expected        medical       professionals  to     members of any civilized society, the
altruistically serve the sick and suffering.        professionals are obligated to practice these
                                                    values. When professionalism in core social
   Some of the virtues a physician needs to         activities such as medicine and law becomes
commit to possess are:                              unsteady, it marks the emergence of societal
     •    Fidelity to trust – essential for         problems. Thus, professional obligations
          establishing rapport and for healing      constitute an important stabilizing and
          to occur;                                 morally protective force in a society. 3
     •    Benevolence – action taken for                   Professionalism obligates doctors to be
          patient's welfare, and avoiding all       competent and updated in their expertise and
          avoidable harm;                           proficiency. It obligates doctors to suppress
     •    Intellectual honesty to accept when       self-interest in their service for the well-being
          one does not know, having the             of their patients. It obligates doctors to
          humility to admit it and obtain           cultivate a fiduciary relationship with their
          assistance and specialist help;           patients and be trustworthy. It obligates
                                                    medical institutions to promote society’s trust
     •    Courage to face the dangers of
                                                    and not undermine it.
          contagion, to possibilities of physical
          harm, and political retribution, and            If medicine is a profession, then the
          deceptions of various kinds; courage      medical team – physicians, nurses, physician
          to be the patient’s advocate in a         assistants, social workers, nutritionists,
          commercialized health care setting;       physiotherapists and other care givers – is a

Regional Health Forum – Volume 10, Number 1, 2006                                                  3
group of professionals obligated to share a         reward.     Besides     the    doctor-patient
core of common professional duties. All             relationship, doctors are also involved in a
members have the ethical responsibility to          range of other fiduciary relationships, as
know and respond to their colleagues’               medical teachers, supervisors, senior
professional duties and to be caring and            colleagues or team leaders.
respectful in their professional interactions
                                                          Inappropriate sexual behavior in
with each other. The professional actions,
                                                    fiduciary relationships is considered sexual
values and commitments of the medical team
                                                    harassment, even if there is no apparent
must be transparent to patients and the
                                                    resistance from the patient or client. In
                                                    anonymous surveys, 3%−10% of doctors
                                                    admit to a sexual relationship with a patient.
Professional Authority                              In an Australian survey, it was found that
                                                    7.6% of psychiatrists, almost all male,
The flip side of professional obligation is         reported erotic contact with patients during or
professional authority, which is derived from       after termination of treatment; about 4% of
technical expertise. To the three types of          male psychiatrists in New South Wales have
legitimate authority that Weber described,          been reported for sexual abuse of patients.6
viz., legal, traditional and charismatic
authority, Parsons added a fourth type: expert
authority, which is most applicable for             Charter on Medical Professionalism1
professionals. People obey orders from
physicians because they believe that                A charter was released by the Medical
physicians possess the expert knowledge that        Professionalism Project, a joint effort of the
they do not have.3                                  American Board of Internal Medicine (ABIM)
                                                    Foundation, the American College of
     In the 1970s, the concept of "expert           Physicians-American Society of Internal
professional authority" was criticized as being     Medicine Foundation, and the European
mostly a sham. Much of the clinical practice        Federation of Internal Medicine, in 2002.
was shown to be merely empirical, not based         This charter has recently been revised.
on scientific evidence, not as uniform as any
scientific practice ought to be and to be                The three guiding principles of the
heavily influenced by economic and                  charter are:
marketing forces. Such harsh criticism has               •    Primacy of patient welfare;
ushered in the current push for practice of
evidence-based medicine and clinical                     •    Patient autonomy, and
outcomes research. 3                                     •    Social justice.
                                                         The 10 professional responsibilities
                                                    included in the charter are:
Unprofessional Relationship
                                                         Commitment to:
"When a doctor does go wrong he is the first
 of the criminals. He has nerve and he has               •    Professional competence;
 knowledge." − Sir Arthur Conan Doyle in                 •    Honesty with patients;
            "The Speckled Band"                          •    Patient confidentiality;
A fiduciary relationship is one in which a               •    Maintaining appropriate relations
person, usually with special expertise, agrees                with patients;
to act in the best interests of the other, e.g. a        •    Improving quality of care;
patient, generally in exchange for monetary

4                                                   Regional Health Forum – Volume 10, Number 1, 2006
     •    Improving access to care;                 want. However, in medicine, the decisions
     •    Just distribution of finite resources;    are now heavily constrained by the payers’
                                                    decisions about whether a proposed
     •    Scientific knowledge;                     treatment is “medically necessary” and
     •    Maintaining trust by managing             appropriately cost-effective. This intrusion of
          conflicts of interest, and                third party payers into the health care
     •    Professional responsibilities.            decision-making process has significantly
                                                    curtailed physicians’ accustomed professional
     A      charter      on      medical/dental     independence.8
professionalism of the University of Western
Ontario derives from the ABIM charter with               While physicians and their professional
minor differences. In lieu of "improving quality    associations are preoccupied with struggles
and access to care," which are system issues        on issues of payment and political power,
beyond the control of an individual                 professionalism is seriously threatened. The
professional, the following principles have         New England Journal of Medicine has
been added.7                                        warned, on behalf of patients, against the
                                                    “new medical-industrial complex” as inimical
     •    Commitment to cooperation and             to the free exercise of professional
          collegiality;                             responsibilities.
     •    Commitment to open and honest
                                                          Another major threat to professionalism
          relationships with colleagues and
                                                    arises from the undue influence of the
          third parties, and
                                                    pharmaceutical industry over continuing
     •    Commitment to improving the               professional education and research. Unlike
          health of the community.                  issues related to managed care, the excessive
      Charters are useful signposts that point      dependence on drug industry is under the
out the correct path that health care               control of physicians and their professional
professionals ought to take. However, critics       associations.8 These issues may well subvert
say that charters and professional resolutions      the effort to make professionalism relevant to
might influence individual behaviour in some        contemporary medicine.
instances, and are doubtful if these would
have substantial collective impact on health
care delivery in the current era of managed
                                                    Challenges to Professionalism in the
care.                                               Third World
                                                     "The medical profession is under siege. The
Threats to Professionalism                            public increasingly distrusts us because we
                                                    are too condescending to listen, too mediocre
There is a profound unease with the seeming            to keep up, and too greedy to truly care
primacy of economic factors currently                    about their welfare." − S.Y. Tan, MD
affecting medical practice in most of the
developed world. A special challenge arises         In India and other developing countries, a
in medicine because health care is often            doctor is greatly trusted, but more and more
expensive and a third party generally               people are questioning the practice.
reimburses these costs. Other professional          However, "my-doctor-knows-what's-best" type
relationships are different: a lawyer or an         of blind trust is giving way, especially among
engineer charges clients directly for services      the educated, to the realization that decision-
rendered, and the clients can consider costs        making is the right of the patient.
when they decide what kind of services they

Regional Health Forum – Volume 10, Number 1, 2006                                                5
     There are numerous instances of                 and medical care and necessary social
unethical advertising by doctors. The                services. These rights raise the ethical issue of
regulatory councils look into such matters but       distributive justice in developing countries
no tangible action is taken and the doctor           where resource crunch is a major problem.
often goes scot-free. Of late, advertisements        How to provide acceptable and affordable
by hospitals and diagnostic centers vie with         care to all is a challenge. Is it ethically
those put up by alternative systems of               permissible for the society to compel
medicine, often proclaiming their superiority        physicians to provide service in under-served
over others.                                         areas and remote villages? Do the
                                                     professional      bodies    not     have      the
      Hi-tech equipments are imported at
                                                     responsibility to influence the health policy
great expense. Most of these equipments are
                                                     and promote distributive justice? Sadly, they
in excess of the needs and paying capacity of
                                                     have, with a few exceptions, been passive
patients. Health care centres use fee-splitting
                                                     spectators in the fight against discrimination
and other incentives to lure referrals from
                                                     in health care. 12
physicians. Is it ethical for the physicians to
order expensive investigations without                     It is perhaps peculiar to India that
explaining to the patient how much it would          modern science is employed for female
cost to undergo the full treatment? It is            feticide. Even after it has been made illegal,
estimated that about two thirds of rural             some doctors in India perform fetal-sex
families are in debt because of health care          determination tests. Such abortion clinics
expenditure.9                                        thrive in the country in spite of the law against
                                                     it. Gender discrimination, loaded against the
      Another major problem in most
                                                     girl child, is however quite prevalent in
developing countries concerning equipment
                                                     developing countries.12
imported from abroad has been the poor
quality of service and maintenance. Is it                  Recent media reports spoke of
ethical to procure costly equipment, which is        'exploitative research' in the developing
not likely to function for long? Is it ethical for   countries. An important safeguard is needed
vendors to supply these items without effective      to avoid the exploitation of potentially
after-sales service? Thairu has suggested that       vulnerable populations in these countries.
manufacturers, vendors and users regarding           Clinical trials should be limited to those that
the sale and maintenance of equipments               are responsive to the host country's health
should agree upon a professional code.10             needs.13
      Another unprofessional facet of health
care in developing countries is the doctors'
tendency to prescribe fashionable and
                                                     Teaching Professionalism
expensive drugs or irrational drugs with                "The practice of medicine is an art, not a
limited therapeutic value. The drug vendors           trade; a calling, not a business; a calling in
and producers 'push' doctors into using their        which your heart will be exercised equally with
products by all means – fair or foul. This is               your head.” − Sir William Osler
responsible for distortions in drug production
and consumption. 11                                  There is widespread concern today among
                                                     conscientious physicians, medical educators
      Article 25 of the Universal Declaration        and the general public that medicine is
of Human Rights states, that everyone has the        becoming ‘unprofessional’ and that the
right to a standard of living adequate to the        profession is losing its commitment to protect
health and well-being of himself and his             the welfare of patients. How should medical
family. This includes food, clothing, housing        schools respond to this challenge?

6                                                    Regional Health Forum – Volume 10, Number 1, 2006
Importance of Role Models                                     of professionalism even as health
                                                              care reform continues, and
Source credibility is an important principle of          •    Empowerment of the learners so
adult learning. Role models are therefore                     that they – the future doctors – can
necessary to impart effective training and
                                                              lead the reform.
inculcate professionalism among learners.
      How can medical schools find
physicians who can, without hypocrisy, teach        A Successful Model
these courses? They have to start with a            The University of Chicago, USA emphasizes
faculty    development      programme        on     six principles (the “Six Cs”) in teaching clinical
professionalism and create a critical mass of       medical ethics.16 The “Six Cs” principles for
role models among the educators. Then they
                                                    teaching clinical ethics are:
have to develop a programme on how best
to transmit those values to the learners.                •    Clinically based – for relevance;
Mentoring is clearly the most effective means            •    Cases (real) – narratives for fidelity
of transmitting values. Another effective way is              and effectiveness;
to create an environment for professionalism,
not by telling students what to do, but by               •    Continuous – reinforcement of
raising their awareness by asking questions.                  learning outcome;
Feedback to tell the learners how they have              •    Coordinated – integrated approach
evolved and rewarding them for their                          of all issues pertaining to the case;
progress is very important as well.14                    •    Clean (i.e. simple case) – for
                                                              clearer take-home messages and
                                                              better impact, and
Relevant Issues for Future Professionals
                                                         •    Clinicians as instructors – for source
Today’s students need skills that will serve                  credibility and all-round case
them well in future. Some of the important                    discussion.
issues for future professionals’ are15:
     •    How forces such as managed care
          and     drug     industry threaten
                                                    Informal Curriculum
          professionalism;                          The social milieu or “informal” curriculum of
     •    How the field of medicine must            a medical school has great influence on
          adapt to the current reality and yet      values and professional identities acquired by
          remain ethical;                           its students. The Indiana University School of
                                                    Medicine, USA runs a programme to foster a
     •    How to practice humanistic and
                                                    social environment that embodies and
          compassionate medicine within the
          10 minutes spent in seeing a              reinforces the values of competency-based
          patient;                                  curriculum. The school uses an appreciative
                                                    narrative-based approach to encourage its
     •    How to truly care for our patients if     students and faculty to be more mindful of
          third party payers (insurance             relationship dynamics. They discover how
          industry) decide which tests and          much relational capacity already exists and
          which medicines are permitted, and        how widespread is the desire for a more
          dictate the time allocated to each        collaborative environment. Their perceptions
          case;                                     of the school seem to shift, evoking
     •    The knowledge and the skills              behaviour change and hopeful expectations
          needed to adhere to the principles        for the future.17

Regional Health Forum – Volume 10, Number 1, 2006                                                   7
      There are further questions that need to              Evaluation
be addressed by every medical school. Some
of them are:                                                Periodic     assessment      of    professional
                                                            behaviour of the residents and other learners
       •         How to overcome the resistance to          is needed. Giving them feedback in a non-
                 teaching professionalism;                  judgemental way helps in further shaping
       •         How to know that the professionalism       their behaviour. In the Department of Internal
                 curricula are working;                     Medicine, we use faculty staff as mentors of
       •         How to develop a reliable and valid        postgraduate residents. The residents are
                 set of professionalism assessments         assessed using the checklist (vide infra) every
                 tools, and                                 six months, leading to five assessments during
                                                            the three-year period. Their progress – or
       •         Does    educating      professional
                                                            lack of adequate progress – is commented
                 behaviour ensure professionalism.
                                                            upon in a non-judgemental way.18

    Resident Evaluation Checklist on Professionalism
    Marking:              0 1 2 3 4           5 6 7 8          9 10
                          Unsatisfactory     Satisfactory    Exemplary
           (1)  Empathy in patient care.
           (2)  Appropriate fund of knowledge.
           (3)  Soundness of clinical judgment.
           (4)  Technical expertise with diagnostic and therapeutic procedures.
           (5)  Communication with patients, families and staff.
           (6)  Sensitivity and responsiveness to individual patient differences in economic status,
                ethnicity, age, gender and disabilities.
           (7) Honesty in dealings with patients and colleagues.
           (8) Accountability for actions.
           (9) Conflict-resolution skills.
           (10) Adherence to regulatory, institutional and departmental norms.

(Modified from − Catherine A. Marco. Medical Professionalism In Emergency Medicine Graduate Medical Education.)

Looking to the Future                                                  undue concern about cost and
                                                                       insurance issues;
Fostering Professionalism − The Milieu                            •    Satisfaction in providing continuity
We ought to create the kind of health care                             of care to patients with chronic
environment which is conducive for                                     illnesses;
physicians to be truly professional, regardless                   •    Building and maintaining trusting
of who controls it – the manager or the                                relationships with patients and with
physician. Some of the major issues in health                          the general public;
care organization and delivery are19:                             •    Opportunities      to      participate
       •         The ability to treat patients, using                  creatively as 'patient advocates' to
                 high standards of care, without                       improve the health care system;

8                                                           Regional Health Forum – Volume 10, Number 1, 2006
      •    Good information systems and                            necessary          to        promote
           audit for more effective patient care                   professionalism and advocacy skills;
           and continuous improvement in                     (5)   Professional        bodies      could
           quality;                                                encourage and protect whistle-
      •    The ability to exercise professional                    blowers, so that the profession is not
           curiosity through meaningful clinical                   dependent on 'outsiders' to identify
           research and outcome assessment;                        and publicize problems;
      •    Open and fair communications with                 (6)   Professional associations could be
           other members of the health care                        expanded the agenda for their
           team, including managers, and                           lobbying and advocacy. The society
      •    Reasonable working conditions and                       will positively respond to advocacy
           income levels.                                          that is driven not by narrow self-
                                                                   interest but by a broader
                                                                   professional vision of patients'
Fostering Professionalism − The Strategies                         welfare;
Ethical principles are difficult to implement in             (7)   Professional societies, medical
a corrupting environment. Therefore, a major                       schools, and teaching hospitals
commitment by all stakeholders to establish                        could be proactive and minimize
and maintain ethical standards in all aspects                      the influence of pharmaceutical
of health care delivery is of paramount                            companies and their represent-
importance.                                                        atives, and
                                                             (8)   The agencies and individuals who
    There are several options but most of                          have done worthwhile acts to
them require a change in the mind-set and                          promote professionalism could be
major departure from current procedures.                           appreciated and rewarded like, the
      (1) Professional and certifying bodies                       awards given by the foundation of
          could regulate rather than merely                        The American Board of Internal
          recommend standards of behaviour                         Medicine. 20
          and service;                                        The    responsibilities  of    fostering
      (2) A requirement to render a minimal             professionalism are indeed awesome. The
          quantum of free care might convey             obvious question is, “Are the key players and
          commitment          to     medical            professional organizations competent and
          professionalism and improve the               willing to move ahead?”
          health of the poor;
                                                             To sum up, how can one prove one’s
      (3) Professional associations could               love to others? It can only be proven by
          form issue-based alliances with               consistently demonstrating love. Similarly, to
          consumer groups to accomplish                 prove their professionalism, the physicians
          goals that neither can realize                can only act as true professionals, striving
          separately;                                   always to deserve the trust and admiration
      (4) The medical curriculum should be              they hope to inspire.3
          revised to inculcate the skills

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      a physician charter. Ann Intern Med 2002;              Parsonian View. The Mount Sinai Journal of
      136:243- 246.                                          Medicine 2002; 69: 393-399.
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      the Virtues of the Good Physician. The Mount           or Treat – a Survival Guide to Health care.
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Regional Health Forum – Volume 10, Number 1, 2006                                                         9
5.    Stevens RA. Themes in the History of Medical              13.   Shapiro HT, Meslin EM. Ethical Issues in the
      Professionalism. The Mount Sinai Journal of                     Design and Conduct of Clinical Trials in
      Medicine 2002; 69: 357-362.                                     Developing Countries. NEJM 2001; 345:139-
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      380-383.                                                        of Medicine 2002; 69: 415-417.
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      University of Western Ontario - available at                    Perspective. The Mount Sinai Journal of Medicine                    2002; 69: 412-414.                                              16.   Siegler M. Training Doctors for Professionalism:
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      2002; 69: 398-403.                                              2002; 69: 404-9.
9.    Anant Phadke et al. A study of supply and use of          17.   Suchman et al., Towards an Informal Curriculum
      pharmaceuticals in Satara district, Mumbai,                     that Teaches Professionalism - Transforming the
      India. FRCH. 1995.                                              Social Environment of a Medical School. J Gen
10.   Thairu, K. Manufacturers and users in joint                     Internal Med 2004; 19: 501-504.
      endeavour. World Health Forum, 1989; 10:23.               18.   Sethuraman KR. Unpublished Official Records.
11.   FME report. "Surviving the Indian Pharmaceutical                Department of Medicine, JIPMER, Pondicherry.
      Jungle - Promotional Practices of Pharmaceutical          19.   Stevens RA. Themes in the History of Medical
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      Available at              Vice-President, ABIM Foundation, on Feb 25,
      044ed115.html.                                                  2005. Available at

Further Reading
1.    Issues in Medical Ethics 2000 Conference. The             6.    Wynia, MK, Latham, SR, AND Kao, AC. Medical
      Mount Sinai Journal of Medicine 2002; 69.6;                     Professionalism in Society. NEJM 1999.
      354-420                                                         341:1612-1616.
2.    Papadakis MA, Loeser H, Healy K. Early                    7.    Crawshaw R, Rogers DE, Pellegrino ED, et al.
      detection and evaluation of professionalism                     Patient-physician covenant. JAMA. 1995;
      deficiencies in medical students: one school’s                  273:1553.
      approach. Acad Med 2001; 76:1100-1106.                    8.    Lundberg GD. The failure of organized health
3.    Rothman, DJ. Medical Professionalism - Focusing                 system reform − now what? Caveat aeger – let
      on the Real Issues. NEJM 2000; 342:1284-                        the patient beware. JAMA. 1995; 273:1539-
      1286                                                            1541.
4.    Swick HM, Szenas P, Danoff D, Whitcomb ME.                9.    Australian Medical Association. AMA position
      Teaching professionalism in undergraduate                       statement: AMA code of ethics - 2003.
      medical education. JAMA 1999; 282:830-832.                      Canberra: AMA, 2003.
5.    Ludmerer KM. Instilling professionalism in
      medical education. JAMA 1999; 282:881-882.

10                                                              Regional Health Forum – Volume 10, Number 1, 2006

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